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CMN568 > Module 5 EB #1 > Flashcards

Module 5 EB #1 Flashcards

1
Q

Red flag sx of acute HA
*what do these red flag sx exclude?

A

> 40yo
rapid onset
severe intensity
**thunderclap
-onset after trauma or during exertion

-brain tumor, meningitis, stroke, encephalitis, intercranial hemorrhage, temporal arteritis, acute angle glaucoma, raised ICP, CO poisoning, preeclampsia, aneurysm

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2
Q

When to transfer to the ED for acute HA (accompanying signs)?

A

-fever, vision change, neck stiffness
-neuro findings: mental status change, motor/sensory deficits, LOC
-past medical hx of HTN or HIV

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3
Q

SNOOOPPPPP

A

-sx of acute HA
-Systemic S or S (fever, wt loss)
-Neurologic S or S (confusion or impaired alertness)
-Onset (sudden)
-Older (>50yo)
-Occipital (back of head; occipital HA in children)
-Previous HA (new, worse, or different?)
-Progressive, persistent HA
-Precipitated by pressure (bearing down, coughing, sneezing)
-Postural HA (worse when supine, worse waking at night, worse in AM)
-Pregnancy

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4
Q

what is the most important component (what info is most important) in regards to acute HA?

A

onset of HA
-sudden, persistence = subarachnoid hemorrhage
–> especially when preceded by exertional activities

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5
Q

Elements to the neuro exam regarding acute HA

A

-VS
-Mental Status
-Motor and Sensory
-Reflexes
-Gait (rapid finger-nose testing)

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6
Q

Ottawa SAH clinical decision scale

A

100% sensitivity in predicting subarachnoid hemorrhage
-40 years or older
-neck pain/stiffness
-witnessed LOC
-onset during exertion
-thunderclap HA (pain peaks w/i 1 sec)
-Limited neck flexion (on exam)

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7
Q

Diagnostic imaging for acute HA

A

No contrast = visualize bone and surrounding soft tissue (blood vessels)

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8
Q

Migraine
-what type of dysfunction?

A

-neuronal dysfunction: a wave of activity by groups of excitable brain cells that trigger chemicals that cause dilation of blood cells –> creates HA
*pain felt by pt triggers more chemicals which leads to further dilation of blood vessels and more painT

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9
Q

Tension HA
-cause?

A

cause unclear
-derivative pain of tension HA has muscular origin

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10
Q

Cluster HA
-mechanism

A

vascular dilation trigeminal nerve stimulation, have circadian effects
-histamine release, inc mast cells, genetic factors, and autonomic NS activation may also contribute

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11
Q

Which HA does this describe?
Unilateral pain, throbbing, pulsitile

A

Migraine

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12
Q

Which HA does this describe?
worse with routine activity

A

Migraine

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13
Q

Which HA does this describe?
onset and duration of HA = 4-72hrs

A

Migraine

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14
Q

Which HA does this describe?
Accompanying sx: N/V, photophobia, phonophobia

A

Migraine

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15
Q

Which HA does this describe?
some have aura preceding AH (commonly visual aura)

A

Migraine

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16
Q

Which HA does this describe?
Family hx of this type of HA present

A

Migraine

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17
Q

Which HA does this describe?
Patient reports recent lack of sleep, missed meal, menstruation

A

Migraine

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18
Q

Which HA does this describe?
precranial tenderness with generalized apin described as vice-like, tight

A

tension

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19
Q

Which HA does this describe?
not pulsitile

A

tension

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20
Q

Which HA does this describe?
pain worse at base of neck or occipital area of head

A

tension

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21
Q

Which HA does this describe?
timing: constant daily HA

A

tension

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22
Q

Which HA does this describe?
no accompanying focal/neuro deficits = NO AURA

A

tension

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23
Q

Which HA does this describe?
episodes exacerbated by stress, fatigue, noise

A

tension

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24
Q

Which HA does this describe?
unilateral, temporal or periorbital pain with one or the following:
-ipsilateral sx: nasal congestion, rhinorrhea, lacrimation, redness of eye

A

cluster

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25
Q

Which HA does this describe?
pain often occurs at night (awakens patient), then have spontaneous remission

A

cluster

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26
Q

Which HA does this describe?
timing: episodic and last 15 min to 3 hours; then have spontaneous remission

A

cluster

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27
Q

Which HA does this describe?
commonly seen in middle aged men ages 20-40

A

cluster

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28
Q

Which HA does this describe?
no family hx of this HA or migraine present

A

cluster

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29
Q

Migraine:
patho

A

brain cells trigger release of chemicals that lead to blood vessel dilation and pain

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30
Q

Migraine:
-drug class most effective for symptomatic or abortive tx

A
  1. ergotamine (narrow blood vessels)
  2. triptans (acts like serotonin; quiets nerves) - constricts blood vessels in brain, slowing inflammation and blocks pain pathways
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31
Q

Migraine
-what should you do for a patient presenting with migraine before prescribing he/she ergotamine or triptans?

A

place pt in cool, dark room; give simple analgesic (tyl, ibup, naproxen) and reassess pain in 30 min

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32
Q

Tension HA
patho

A

muscular tension primarily in shoulders, neck leads to pain

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33
Q

Tension HA
-drug class most effective for symptomatic tx

A

No triptans; address comorbid issues, CBT, etc.
Similar to migraine tx –> prescribe simple analgesics

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34
Q

Cluster HA
-patho

A

myriad of reasons but similar to migraine HA etiology (brain cells trigger release of chemicals that lead to blood vessel dilation and pain)

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35
Q

Cluster HA
-Drug class most effective for symptomatic or abortive tx

A

TRIPTANS (sumatriptan SQ or intranasal)
O2 inhaled 100% in nonrebreather mask

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36
Q

Tension HA
-what medications can you consider?

A

muscle relaxers
-flexeril
-zanoflex
-robaxin

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37
Q

Can abortive drugs be given during pregnancy for HA?

A

NO

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38
Q

Which type(s) of HA can recur?

A

Migraine and cluster
-HA that occurs 2-3x/MO or significant disability associated with attack

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39
Q

Migraine HA
-prescribe prophylactic/preventative med (how many options total?)

A

Topiramate
Valproic acid
Propanolol
Verapamil
Amitriptyline
Botox
Riboflavin
(7)

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40
Q

Cluster HA
-prescribe prophylactic/preventative med

A

Lithium
Topiramate
Verapamil

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41
Q

foods that trigger migraine or cluster AH

A

chocolate and ETOH

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42
Q

Considerations in HA management

A

avoid opioid meds d/t SE (including rebound HA)
keep HA diary to identify triggers and avoid any precipitating factors if known

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43
Q

Other HA disorders

A

-posttraumatic HA
-analgesic rebound HA
-primary cough HA
-HA d/t intracranial mass

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44
Q

Posttraumatic HA
-def
-how quickly does HA appear? does it worsen?
-sx
-tx

A

-HA following closed head injury regardless of LOC
-pain appears w/i 24 hours; worsens over weeks but gradually subsides
-constant dull ache; can be localized, lateralized or generalized; associated with N/V, seeing black spots - scintillating scotoma
-simple analgesics (tyl, ibup)

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45
Q

Analgesic rebound HA
-def
-how long do these meds need to be used to become a risk factor?
-simple analgesic effects (timeline)
-tx

A

-using ergotamines, triptans, opioids, and meds containing butalbital (fioricet)
-for more than 10 days per MO
-simple analgesics (tyl, acetylsalicylic acid, NSAIDs) taken more than 15 days per MO
-“fix the why” - prescribe preventative tx for migraines so they will stop using these meds as frequently (topiramate, valproic acid, verapamil, amitriptyline, botox, riboflavin, propanolol)

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46
Q

Primary cough HA
-def
-what should you be thinking? what should you order?
-tx

A

-pain with coughing, straining, sneezing, laughing (only lasts a few minutes)
-THINK BRAIN TUMOR. Order CT or MRI
-once brain tumor is r/o, NSAID (indomethacin)

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47
Q

HA d/t intracranial mass
-when does this tend to occur (age)? what should you order?
-aggravating factors
-how does body counteract inc ICP in this state?
-associated systemic signs that may be associated w/ this?

A

-new or worsening HA in middle or later life; order MRI or CT
-worse when lying down; awakens the patient at night (same as cluster HA :) ); peaks in the AM after overnight recumbency
*lying down increases CIP but our SCF and spine can adjust for this; with a tumor, prevents feedback system from operating as normal and leads to inc ICP
-body’s natural response to counteract inc ICP is to keep you upright
-fever, night sweats, weight loss

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48
Q

facial pain: trigeminal neuralgia
-where is the pain felt? descriptor of pain?
-what makes this pain worse?
-is neuro exam abnormal or normal?
-can remission occur?
-effect women or men more? at what point of life does this tend to occur?

A

-unilateral stabbing pain localized to the second and third division of the trigeminal nerve = pain arising at one side of the mouth and shoots toward the eye, ear, or nostril ON THAT SIDE
-with touch (even air hitting face)
-normal
-yes
-women; middle and later life

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49
Q

Facial pain: trigeminal neuralgia
-why does this occur?
-tx

A

-impinging of trigeminal nerve leads to misfiring and nerve pain
-carbamazepine - decreases nerve impulses that cause seizures and pain (anticonvulsant)

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50
Q

Facial pain: trigeminal neuralgia
-when to expect MS with these sx?
-drug of choice for MS and trigeminal neuralgia

A

-<40yrs
-gabapentin

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51
Q

Facial pain: posttherpetic neuralgia
-what should we be thinking?
-who is this common in (what population)?
-sx
-what aids in dx?
-tx
-prevention
*what NOT TO DO

A

-herpes zoster (singles)
-elderly/immunocompromised; when first division of trigeminal nerve is affected
-severe visible rash (when first division of trigeminal nerve is affected - rash on forehead, bridge of nose)
-hx of shingles and presence of cutaneous scaring
-acyclovir or valacyclovir when given >3hrs after rash onset
-shindrix vaccine
*DO NOT ADMINISTER SYSTEMIC CORTICOSTEROIDS: weakens immune system, makes virus/rash worse

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52
Q

Facial Pain: TMJ
-def
-sx
-tx

A

-due to injury to jaw, joint, or muscles of head and neck; grinding/clenching of teeth, or stress causing one to tighten facial/jaw muscles
-pain, tenderness in face, jaw joint area, around ear w/ chewing, speaking, opening mouth wide; jaw can get struck; clicking, popping, grinding sounds of jaw with opening/losing/chewing = can be painful
-simple analgesics; sometimes muscle relaxants (refer to dentist - mouthguard?

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53
Q

Facial pain: SAH
-most common cause?
-other causes?
-risk factors?
-what do patients present with?
-role of NP
-med

A

-trauma
-rupture of arterial saccular “berry” aneurysm or an AVM (from high BP?)
-older age, female, nonwhite ethnicity, HTN, smokier, consuming large amounts of alc
-present with sudden severe HA (WORST HA they have ever experienced); proceed to vomit
*signs of meningeal irritation (stiff neck, dec neck flexion are common): transient LOC, appear confused/irritable, progresses to coma; focal neuro deficits are ABSENT
-stat transfer to ER for CT; neuro surgery consult; ICU admission
-nimodipine = reduces iscehmic deficits from arterial vasospasm

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54
Q

Facial pain: pseudotumor cerebri - “Idiopathic Intracranial HTN”
-def
-RF
-etiology (most common)
-S/S
-NP role
-meds

A

“False Brain Tumor”
-pressure around brain inc; causes HA and vision problems (double vision)
-overweight women 20s-40s
-(many) - thrombosis of transverse sinus (complication of otitis media) is the most common; abrupt cessation of PO steroids; long-term use tetracycline or PO contraceptives
-worsened by straining; fondoscopic exam reveals edema and abducens palsy (causes eyes to turn out); chronic IH will cause pulse incronis tinnitis
-REFER to ER for CT; r/o emergent HA causes including space occupying lesions of the brain
-initiated and managed by neuro

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55
Q

Adjustment disorders
-def (when did stressor occur?)
-common rxns to stress
*does this resolve?
-tx

A

-signs of anxiety/depression d/t identifiable stressor that has occurred in past 3MO; sx are out of proportion to the severity of the stressor but not as severe as major depression or GAD
-manifests as developing somatic complaints: running away, drinking ETOH excessively, over eating, starting an affair
-this condition is completely situational; usually resolves when stressor resolves or when individual effectively adapts to situation
-behavioral techniques: CBT with emphasis on strengthening existing coping methods); lorazepam (for limited time)

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56
Q

trauma and stressor-related disorders: PTSD
-key to dx
-sx
-more common in which sex?
-tx

A

-establish if pt experienced a traumatic or life threatening event
-flashbacks, obtrusive images/intrusive thoughts, nightmares; pt feels like they experience moment repeatedly; causes pt to avoid stimuli that could be associated with the event
-more common in women and when event is associated with physical injury
-centered around interventions that will help pt integrate the event in an adaptive way
*psychotherapy: initiate ASAP; brief 8-12 sessions
*drug of choice: SSRIs: sertraline and paroxetine + others

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57
Q

Anxiety
-sympathomimetic sx of anxiety
-impact of trigger avoidance
-what is a contributing factor to anxiety?

A

-response to a CNS state that perpetuates further anxiety (fight or flight) –> anxiety can be self-perpetuating
-reinforcement of the anxiety (person continues to associate trigger w/ anxiety and never relearns through experience that the trigger need not always result in fear, or that anxiety will naturally improve with prolonged exposure to an objectively neutral stressor)
-lack of structure is frequently a contributing factor; no thoughts to occupy their time leads to over-thinking

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58
Q

Generalized Anxiety Disorder
-short term or chronic? which sex is this more common?
-sx + how long do sx need to be present for dx
-triggers
-physical manifestations
-tx

A

-chronic, women
-apprehension, worry, irritability, difficulty concentrating, insomnia; must be present (more days than not) for at least 6MO
-everyday activities
-tachycardia, HTN, nausea, epigastric pain, HA, near-syncope
-SSRI (venlafaxine, duloxetine) or SNRI (escitalopram, paroxetine)

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59
Q

Phobia disorder
-short term or chronic?
-def
-debilitating fears
-tx

A

-chronic, specific object or situation
-fear out of proportion to the danger posed
-debilitating fears: social phobia - patient remains isolated at home
-desensitization; SSRI (venlafaxine, duloxetine) or SNRI (escitalopram, paroxetine)

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60
Q

Panic disorder: panic attack
-def
-sx
-key to dx

A

-recurrent, unpredictable episodes of intense surges of anxiety and marked physiologic manifestations = impending doom
*pt appears dyspneic, tachycardic, report palpitations, HA, dizziness, numbness of extremities, feeling smothered or nauseous, bloating
-psychic pain and suffering the individual expresses

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61
Q

Panic disorder: panic disorder
-def
-RF
-what can this presentation mimic?
-tx

A

-dx when panic attacks are accompanied by a chronic fear of the recurrence of an attack or a maladaptive change in behavior = try to avoid potential triggers of the panic attack
-family hx, female, premenstrual period, mitral valve prolapse
-MIMIC a cardiac event = MI must be ruled out w/ EKG and cardiac enzymes
-SSRI (venlafaxine, duloxetine) and SNRI (escitalopram, paroxetine)

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62
Q

Panic disorder
-2 categories
-complications
-must R/O what?
-first line tx:
-first line drug class

A

-panic attack, panic disorder
-inc risk of major depression or suicide attempts; ETOH abuse and dependence on sedatives
-cardiovascular, endocrine, respiratory, neurologic, substance related syndromes
-psychotherapy (CBT)
-SSRIs (venlafaxine, duloxetine) or SNRIs (escitalopram, paroxetine)
**antidepressants take approx 2-4 weeks before effective
**abrupt withdrawal can lead to suicidal thoughts

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63
Q

abrupt withdrawal of antidepressants (SSRI and SNRI) can lead to what?

A

suicidal thoughts

64
Q

OCD
-def
-2 components
-what does it often coexist with?
-prevalence
-tx

A

-irrational idea or impulse repeatedly and unwantedly intrudes into awareness; anxiety so overwhelming that only alleviated by ritualistic performance of the compulsion; chronic disorder that waxes and wanes
-obsessions (recurring distressing thoughts); compulsions (repetitive actions); unwanted by patient
-major depression
-equal among sexes; highest rates in young, divorced/separated, unemployed individuals
-SSRIs, tricyclic antidepressant clomipramine + CBT
*thought-stopping

65
Q

somatic sx disorders (abnormal illness behaviors): somatic sx disorder
-chronic or temporary?
-complaint of pt?
-onset; more common in men or women?

A

-chronic
-complains of one or more somatic sx exhibited as disproportionate and persistent thoughts about the seriousness of the sx
-usually before 30 yrs of age; 10x more common in women

66
Q

somatic sx disorders (abnormal illness behaviors): conversion disorder
-def
-tends to occur simultaneously with what?
-somatic manifestation:

A

-“conversion” of psychic conflict into physical neurologic sx in parts of body innervated by the sensorimotor system (ie paralysis)
-panic disorder or depression
-takes the place of anxiety; is often paralysis

67
Q

somatic sx disorders (abnormal illness behaviors): factitious disorders
-def
-munchausen syndrome
-munchausen by proxy

A

-sx production is intentional; pt consciously produces sx; characterized by self-induced or described dx or false physical and laboratory findings for the purpose of deceiving clinicians or other healthcare personnel (common deceptions: self-mutilation, fever, hemorrhage, hypoglycemia or seizures)
-self-inflicted
-factitious disorder imposed on another

68
Q

somatic sx disorders (abnormal illness behaviors):
-tx (for somatic sx disorder, conversion disorder, factitious disorder)
*what is a mainstay of tx?

A

-multifaceted
*behavior: biofeedback
*social: family member involvement
*psychological: PCP establishes relationship with patient

**medical support with careful attention to building a therapeutic clinician-patient relationship is a mainstay of tx

69
Q

Chronic Pain Disorders
-essentials of dx
-what is counterproductive?

A

-chronic complains of pain
-sx frequently exceed signs
-minimal relief with standard tx
-hx of “doctor shopping”
-frequent use or several nonspecific meds
**it is counterproductive to speculate about whether pain is real

70
Q

Chronic pain disorders
-medical tx
*what is the highest priority?

A

-medically treating the pt with a single clinician in charge of the comprehensive treatment approach

71
Q

Chronic pain disorders
-behavioral tx
*what should be identified?
*what type of therapy is helpful?
*first line tx of choice for neuropathic pain?
-other meds used?

A

-identify and eliminate pain reinforcers to decrease med use
-group therapy with family is helpful
-SNRIs: venlafaxine, duloxetine
-anticonvulsants (gabapentin, pregabalin) and TCA (nortriptyline)

72
Q

what meds can help treat fibromyalgia?

A

-anticonvulsants, duloxetine + milnacipran

73
Q

Depression
-def
-what is a common presentation of depression?

A

-mild sadness to intense despondency and feelings of guild, worthlessness, hopelessness; inability to concentrate, ruminations, lack of decisiveness; loss of interest + decrease work/recreation involvement; excessive sleep, loss of sleep, change in appetite, dec libido, suicidal ideations
-somatic complaints with negative medical work-up

74
Q

Mania
-def

A

-euphoria to irritability
-insomnia, hyperactivity, racing thoughts, pressured speech; grandiosity with extreme overconfidence; variable psychotic sx

75
Q

Adjustment disorder presenting with depressed mood
-def
-when does this type of depression subside?

A

-depression in reaction to an identifiable stressor or adverse life situation; subside when stressor removed

76
Q

Major depressive disorder
-def
-sx
-do sx improve?

A

-syndrome of mood, physical and cognitive sx that occurs at any time of life
-loss of interest and pleasure, withdrawal from activities, feelings of guild; inability to concentrate, some cognitive dysfunction, anxiety, chronic fatigue, feelings of worthlessness, somatic complaints (unexplained somatic complaints frequently indicate depression), loss of sexual drive, thoughts of death; insomnia anorexia w/ wt loss, constipation
-improvement as the day progresses

77
Q

dysthymia
-def
-sx
-how long must pt suffer until dx?
-sx in relation to MDD

A

-chronic depressive disturbance expressed in those with MDD
-sadness, loss of interest and withdrawal from activities
-sx are over a period of >2years or more, with a relatively persistent course
-sx are milder, but last longer than MDD

78
Q

Premenstrual dysphoric disorder
-def

A

depressive sx during the late luteal phase (last 2 weeks) of menstrual cycle

79
Q

Bipolar disorder
-def
-two types

A

-episodic mood shifts into mania, major depression, hypomania, mixed mood states; bipolar mimics several other major mental disorders
-bipolar I and bipolar II

80
Q

Bipolar disorder: bipolar I
-def

A

has manic episodes only

81
Q

Bipolar disorder: bipolar II
-def

A

individuals who experience hypomanic episodes without frank mania

82
Q

Bipolar disorder: mania
-def
-are onset of episodes abrupt or drawn out?
-how long to episodes last?
-sx
*definition of Rapid cycling (what is there a higher incidence of?)

A

-mood state characterized by elation with hyperactivity, overinvolvement in life activities, increased irritability, flight of ideas, easy distractibility, and little need for sleep; initially attractive to others but then become irritable with swings into depression, aggression, grandiosity
-abrupt (sometimes caused by life stress)
-may last several days to months (manic modes are of shorter duration than depressive episodes
-pts excessively spend money, resign from job, hasty marriage, sexual acting out, alienation of friends and family
*4 or more discrete episodes of mood disturbance in 1 yr (higher incidence of hypothyroidism)

83
Q

Cyclothymic disorder
-def
-similar to what?
-dx

A

-chronic mood disturbances + episodes of subsyndromal depression and hypomania; alternates between hypomanic sx and mild/moderate depressive moods
-similar to bipolar II
-sx must be present for at least 2 years and are milder than those that occur in depressive or manic episodes

84
Q

Drug-induced depression
-common meds

A

-corticosteroids
-PO contraceptives
-digitalis
-clonidine
-levodopa
-interferon
-stimulants (when they have depressive syndrome during withdrawal)
-use of depressants (ETOH, sedatives, opioids)

85
Q

complications associated with depression
-most important complication
-R/F

A

-suicide
-bipolar I disorder, men >50yo, women, comorbidities ie CA, COPD, AIDS, those on hemodialysis, those who drink ETOH

86
Q

what is a MAJOR RED FLAG for IMPENDING SUICIDE?

A

a depressed pt who makes dramatic improvement

87
Q

Depression
-tx

A

CBT +
SSRIs or SNRI
TCAs and MAOI
Atypical (Wellbutrin)

electroconvulsant therapy ECT

88
Q

what is the most effective tx for depression?

A

CBT + med

89
Q

Depression (tx)
-SSRI or SNRI
*fluoxetine - SE
*pt with cardiac hx, what to prescribe?

*what are patients at risk for when taking SSRIs?

A

-Prozac: long time used, old drug; very trusted. SSRI. Drug of choice for those who have never been prescribed meds before; sexual SE most common complaint
-sertraline (zoloft)

*serotonin syndrome: occurs w/ ingestion of high doses of SSRIs and present w/ sx of rigidity, hyperthermia, autonomic instability, myoclonus, confusion, delirium, coma

90
Q

Depression
-what is the tx drug class of choice?

A

SSRI or SNRI

91
Q

Depression (tx)
-TCAs
*how often are these used

A

rarely d/t drug interactions

92
Q

Depression (tx)
-atypical med (what’s it called)
-SE

A

Wellbutrin
-used widely now d/t weight loss and sexual arousal SE; great choice for someone never on meds who is interested in losing wt

93
Q

what occurs with abrupt cessation of SSRIs or SNRIs?
how should med be discontinued?

A

-can precipitate sx of withdrawal and/or suicidal thoughts
-must reduce gradually over period of weeks or months

94
Q

Depression (tx)
-teratogenic meds

A

SSRIs

-fluoxetine (prozac)
-sertraline
-venlafaxine
-citalopram

95
Q

SSRI
-what risk is increased?
-what SSRI is drug of choice if pt taking warfarin?

A

-bleeding (affects platelet serotonin levels and creates abnormal bleeding)
-sertraline and citalopram

96
Q

How to switch from one depression drug class to another

A

-if switching one drug class to another, wait 2-3 weeks between
-if switching between meds w/i same drug class, no wash out time needed

97
Q

what is the most effective form of tx for severe depression
(when should it be used?)

-who can this therapy NOT be performed on?

A

-electroconvulsant therapy ECT
-used when medical conditions preclude the use of antidepressants or there is a nonresponsiveness to these meds and extreme suicidality
-those with cardiac disorders, bronchopulmonary disease (COPD, asthma), venous thrombosis hx, or hx of aortic aneurysm

98
Q

Bipolar (tx)
-used combination of what?
-med types for each

A

-combination of antipsychotics and mood stabilizers

-antipsychotics: faster acting drugs that begin easing sx w/i hrs
-mood stabilizers: slow and steady mechanism; takes few wks to kick in; even out swings in mood

-antipsychotics: olanzapine (zyprexa), quetiapine (seroquel), risperidone, aripiprazole (ability), clozapine (clozaril)
-mood stabilizers: lithium, tegretol, depakote, lamictal, valproic acid, depakene

99
Q

what is lithium toxicity?
-causes

A

> 2mEq/L
-any Na+ loss

100
Q

drug interactions with lithium?

A

diuretics (need to inc lithium)
ACE-inhibitors (need to dec lithium)

101
Q

Bipolar (tx)
-meds (quick notes about each)

A

-lithium (>2mEq/L; caused by loss of Na+, drug interactions)
-antipsychotics (for acute mania)
-valproic acid (first line tx for mania; treats mania, panic disorder, migraine HA; drug interactions)
-carbamazepine (used when lithium not an option; significant teratogenic effects; many drug interactions (less than lithium)
-lamotrigine (maintenance tx of bipolar - not effective in acute mania; CANNOT be given w/ valproic acid - toxicity; STOP med if rash, fever, lymphadenopathy, oral mucosa ulcerations)

102
Q

what can valproic acid be used to treat?

A

mania, panic disorder, migraine HA

103
Q

Insomnia
-def
-assess for:
-psych disorders related to persistent insomnia
-tx

A

-difficulty initiating or staying asleep w/ intermittent wakefulness during night; early morning awakening, or any combo of these
-excessive alc use; heavy smokers; withdrawal from sedatives; use of stimulants; other causes - stress, physical discomfort, chronic conditions (sleep apnea, RLS), daytime napping, early bedtimes, screen use before bed
-depression; manic disorders (decreased total sleep time + decreased need for sleep are cardinal features and important early sign of impending mania)
-good sleep hygiene; meds: sedative hypnotics (benzo’s) are last resort; drug class of choice = short acting benzodiazepines (lorazepam, Ambien)
*in elderly, trazadone

104
Q

types of hyperinsomnia

A

-obstructive sleep apnea
-Narcolepsy
-periodic limb movement

105
Q

what is the most common sleep disorder?

A

sleep apnea

106
Q

narcolepsy
-def
-when does it begin? which sex is more common?
-trigger?
-cataplexy
-tx

A

-abrupt transition into REM sleep
-begins in early adult life; males and females equally; severity levels off by 30’s
-strong emotional trigger will cause a cataplexy (sudden loss of muscle tone)
-stimulants (modafinil and armodafinil; destroamphetamine)

107
Q

Periodic limb movement disorder (RLS)
-def
-tx

A

-occurs only w/ sleep with subsequent daytime sleepiness, anxiety, depression, cognitive impairment (RLS occurs while awake as well)
-requip, neuropro, mirapex

108
Q

Parainsomnias
-def
-most common in what population/age group?

A

-abnormal behaviors in sleep (sleep terrors, nightmares, sleep walking, enuresis)
-more common in children

109
Q

Common disorders with acts of aggression

A

depression, schizophrenia, personality disorders, mania, paranoia, temporal lobe dysfunction

110
Q

Meds and illicit drugs that produce aggression

A

anabolic steroids, amphetamines, crack cocaine, phencyclodine

111
Q

disorders of aggression
-tx

A

-psychological (often refused)
-pharmacological: antipsychotics (drug class of choice)

Buspirone: anxiolytic that treats sx of fear, tension, and irritability (taken daily, unlike Xanax which is PRN)

112
Q

Alcoholism use disorder
-a drink
-at risk drinking

A

-12oz beer, 8oz malt liquor, 5oz wine, 1.3oz shot
-repetitive use of ETOH often to alleviate anxiety or solve other emotional problems (inc risk for developing ETHO disorder). >4 drinks/day, 14 drinks/wk men; >3 drinks/day, 7 drinks/wk women

113
Q

Alcoholism use disorder
-acute intoxication
-intoxication
-lethal range

A

-legal limit for driving under the influence (legal limit for driving is 80mg/dL)
-ataxia, dysarthria, N/V, drowsiness, errors of commission, psychomotor dysfunction, disinhibition, nystagmus (>150mg/dL)
-respiratory depression, stupor, seizures, shock syndrome, coma, death. Serious overdoses d/t combo alc with other sedatives (350-900mg/dL)

114
Q

Most definitive biologic marker for chronic alcoholism?

A

carbohydrate deficient transferrin
-GGT and MCV if elevated indicate serious alcohol problem as well.

115
Q

Alcohol withdrawal
-when does it occur? sx?
-severe major withdrawal: when does it occur? sx?
-withdrawal seizures
-delirium tremons (DT)

A

-w/i 6hrs; tremors, anxiety, tachycardia, N/V, insomnia
-w/i 48-96hrs; disoriented, agitated, diaphoretic, whole body tremor; vomit, high BP, reports visual, tactile, or auditory hallucinations
-can occur 8hrs after last drink, but usually won’t manifest until >48hrs after alcohol has stopped
-48-72 hours after last drink; may occur 7-10 days later; most severe form of alc withdrawal

**detoxing from alc can kill patient

116
Q

wernick-korsakoff syndrome
-what kind of deficiency?
-d/t what?

A

d/t thiamine deficiency; caused by chronic alcoholism

117
Q

wernicke-encephalopathy
-causes what?

A

causes brain damage –> in lower parts of brain (thalamus, hypothalamus)

118
Q

korsakoff psychosis
-d/t what?
-how to treat?

A

-results from permanent damage to areas of the brain involved with memory
-exhibit confusion, ataxia, anterograde or retrograde amnesia
-early recognition and tx w/ IV thiamine is necessary to dec damage

119
Q

Alcoholism
-tx

A

-antabuse (disulfiram): creates toxic rxn when alc consumed, ie violent vomiting
-naltrexone: opioid antagonist; lowers relapse rates over 3-6M after cessation of drinking
-acamprosate: reduces cravings, maintains abstinence

120
Q

Alcoholism
-tx of acute withdrawal sx

A

-in ER with IV benzo’s; outpatient with short course diazepam with taper dose

121
Q

CIWA-Ar score

A

tool used to determine sx severity of withdrawal
-max score 67
-0-9 absent
-10-15 mild
-16-20 moderate
-21-67 severe

122
Q

Other drug and substance dependencies: opioids
-sx of intoxication
-sx of overdose
-tx

A

-mood, feelings of euphoria; drowsiness; N; needle tracks; miosis
-resp depression, peripheral vasodilation, pinpoint pupils, pulmonary edema, coma, death
-Methadone (use when off opioids for 7-10 days already)
-Suboxone (partial agonist)

123
Q

grades of withdrawal (from drug and substances)

A

0 craving and anxiety
1 yawning, lacrimation, rhinorrhea, perspiration
2 previous sx + mydriasis, piloerection, anorexia, tremors, hot/cold flases w/ generalized acting
3 and 4 inc intensity of previous sx w/ inc temp, BP, pulse, and resp rate and depth

124
Q

Other drug and substance dependencies: Psychedelics (LSD, etc.)
-initial sx
-later sx
-tx
*bad trip
*flashback

A

-tension to emotional release
-hallucinations, erratic behavior
*protect pt from erratic behavior; severe cases = antipsychotic (haloperidol)
*short course of an antipsychotic drug (olanzapine, risperidone)

125
Q

Other drug and substance dependencies: phencyclidine (psychedelic drug mimic)
-presents with what sx?

A

presents w/ disorientation and detachment from surroundings

126
Q

Other drug and substance dependencies: marijuana
-causes what?
-dx with what test?

A

-less inhibited emotions, impaired immediate memory, conjunctival injection (redness)
-urine test

127
Q

Other drug and substance dependencies: stimulants (amphetamines and cocaine)
-cocaine
*sx
-amphetamines
*when does tolerance develop?
*sensitization

A

-dilated pupil, euphoria; unexplained nasal bleeding
-tolerance develops quickly; sensitized to future use of stimulants (even small amounts of mild stimulants (caffeine) can cause sx of paranoia and auditory hallucinations

128
Q

Other drugs and substance dependencies: caffeine (along with nicotine and alcohol)
-what does caffeine improve?
-what do chronically depressed patients use to self-medicate?
-sx of withdrawal

A

-performance (with 30-200mg/day)
-use caffeine drinks as self-medication; diagnostic clue may help distinguish some major affective disorders
-HA, irritability, lethargy, occasional N

129
Q

Childhood psych disorders: anxiety
-different or same as adults? explain.
-can benzo’s be prescribed?

A

same as adults except first line tx
-CBT with exposure is first line tx; if unsuccessful, fluoxetine or prozac is prescribed as first line drug (kids 8yrs and older)

**NO BENZOS!

130
Q

Childhood psych disorders: separation anxiety
-how is this diagnosed?
-tx

A

-4 weeks + significant distress
-CBT (if unsuccessful, SSRI)

131
Q

Childhood psych disorders: selective mutism disorder
-stipulations with dx
-tx

A

-pt cannot have autism, cannot be d/t communication or psychotic disorder
-CBT (if unsuccessful, SSRI)

132
Q

Childhood psych disorders: phobias
-same or different from adults?
-tx?

A

same as adults
-CBT

133
Q

Childhood psych disorders: panic disorder
-same or different from adults?
-when is it likely to present?
-R/F
-Tx

A

-same
-after puberty; likely to have stressor preceding onset
-separation anxiety
-CBT (if unsuccessful, SSRI **NO BENZOS)

134
Q

Agoraphobia
-def

A

fear of open spaces
-an excessive fear of being in a situation where panic-like sx might occur (avoidance of situations that can cause panic to occur)

135
Q

Childhood psych disorders: generalized anxiety disorder
-same or different from adults? explain?
-what kind of complaints to these pts have?
-tx

A

-same
*young kids worry about competence or performance
*older kids worry about issues like family finances
-somatic complaints: GI upset, HA are common
-psychotherapy is first line (SSRI can be added if insufficient)

136
Q

Childhood psych disorders: social anxiety disorder
-same or different from adults?
-tx?

A

-same
-CBT (SSRI is ineffective)

137
Q

Childhood psych disorders: OCD
-when does onset occur (which sex has earlier onset)?
-what does sudden onset of sx warrant?
-tx
-if patient exhibits WHAT = increased risk of comorbidities?

A

-childhood w/ males having earlier onset (before age 10y)
-group A strep screening
-first line: psychoeducation but combo of CBT and meds is the best therapy (SSRIs –> fluvoxamine and sertraline are FDA approved specifically for OCD)

138
Q

Childhood psych disorders: depression
-how to identify depression
-how often should children be screened? at what age?
-scales to assess pediatric depression?
-tx

A

-ask pt about sx
-annual screening for depression in 12yrs old or older
-beck depression scale or PHQ-9 Modified for Teens
-CBT + fluoxetine

139
Q

what are SNRI’s contraindicated with?

A

HTN

140
Q

do not take SSRI with what drug?

A

tryptophan = causes serotonin syndrome

141
Q

Childhood psych disorders: disruptive mood dysregulation disorder (DMDD)
-def
-onset of illness
-which sex is more at risk
-tx

A

-persistent irritability and severe behavioral outbursts at least 3x weekly for 1 year or more; mood in between these sx is persistently negative, irritable, angry and sad; must occur in 2 settings
-prior to 10yrs old
-males
-therapy for kid and family

142
Q

Childhood psych disorders: suicide in children and adolescents
-who is at highest risk?
-when do you routinely assess for suicide risk in pediatric population?
-what warrants immediate referral for psych crisis assessment (ER)?

A

-white adolescent boys
-assess suicide risk routinely in kids 12yrs and older
-suicidal ideation accompanied by any plan warrants immediate referral for psych crisis assessment in nearest ER

143
Q

Disruptive, impulse-control, and conduct disorders: oppositional defiant disorder
-essentials of dx and typical features
-more common in what environment?
-at what age is the evident at?
-tx

A

-pattern of hostile, negativistic, defiant behavior lasting at least 6MO (does not meet criteria for conduct disorder)
-families w/ caregiver dysfunction, substance abuse, parental psychology psychosocial stress (more common among kids w/ hx of multiple changes in caregivers, inconsistent, harsh, neglectful parenting; or serious marital discord)
-evident by age 8
-recommend support for parenting skills; assess for comorbid conditions (ADHD, depression, learning disabilities)

144
Q

Disruptive, impulse-control, and conduct disorders: conduct disorder
-characteristics
-tx

A

-family dysfunction, poverty, abuse, violence, ADHD, learning disabilities, mood disorders; persistent pattern of behavior that includes:
*defiance of authority
*violating rights of others or society’s norms
*aggressive behavior toward persons, animals, property
-stabilize environment, improve home functioning; ID learning disabilities. NO MEDS ARE EFFECTIVE

145
Q

Somatic symptom and related disorders: conversion disorder
-tx

A

reassure child and family that sx are a rxn to stress; encourage to continue normal daily activity; use noninvasive techniques (PT); if sx don’t resolve, refer to mental health specialist

146
Q

what are conversion disorders associated with?

A

sexual over stimulation or abuse

147
Q

Microhematuria
-def
-dx

A

-painful hematuria in children; should be investigated for UTI; associated with back pain/fever = suggests pyelonephritis
-urine dipstick eval but verify by microscopic RBC count

148
Q

Glomerulonephritis
-features

A

-hematuria, edema, HTN, RBC cast in urine

149
Q

Acute glomerulonephritis
-S/S
-affected children require eval of WHAT?
-when is renal biopsy needed?

A

-hematuria, urinary RBC casts, HTN, edema (periorbital facial, extremities, ascites d/t salt and H2O retention w/ impaired glomerular fx –> manage with diuretics)
-eval of BP, renal fx, serum albumin, urine/protein excretion
-when etiology of glomerulonephritis is unclear

150
Q

Acute postinfectious glomerulonephritis
-dx
-manifestations
-tx

A

-dx of acute poststreptococcal GN; supported by recent hx (7-14days) of group A strep infection (usually pharyngitis or less common impetigo)
-asymptomatic microhematuria to gross hematuria
-no tx required, full recovery occurs

151
Q

Acute interstitial nephritis
-commonly caused by WHAT?
-sx
-dx
-tx

A

-drug related w/ B-lactam-containing antibiotics or NSAIDS; also infectious etiologies (ie Epstein-Barr virus)
-fever, rash, eosinophilia may occur w/ drug associated cases (urinalysis usually reveals leukocyturia and mild hematuria + proteinuria)
-renal biopsy –> demonstrates characteristic tubular and interstitial inflammation
-immediate identification and removal of causative agent whenever possible; tx with corticosteroids can be helpful in pts w/ renal insufficiency or associated nephrotic syndrome (dialysis support occasionally needed)

152
Q

Idiopathic nephrotic syndrome of childhood
-classic features
-what is required for tx?
-when is onset? (age)

A

-proteinuria, hypoalbuminemia, edema, hyperlipidemia, clinical findings
-require corticosteroid tx
-<6yo at onset

153
Q

UTI
-at what age to girls have more UTIs than boys?
-most common organisms?
-NB sx
-preschool children sx
-school-aged children sx
-dx
-tx

A

-6MO
-E coli, klebsiella, proteus, gram-negative bacteria
-nonspecific: fever, hypothermia, jaundice, poor feeding, irritability, vomiting, failure to thrive, sepsis
-abd/flank pain, vomiting, fever, urinary frequency, dysuria, urgency, enuresis
-classic signs of cystitis (frequency, dysuria, urgency)
-gold standard is urine culture
-uncomplicated: tx for 7-10d, amoxicillin, bactrim, first gen cephalosporin

154
Q

HA in children
-most common types in children

A

-migraine and tension

155
Q

Migraines in children
-same or different sx than adults?
-tx

A

-same
-use of simple analgesics (acetaminophen, ibup) is the first line therapy; FDA approved med almotriptan (approved for ages 12-17) and vizatriptan (approved for ages 6-17)

156
Q

prevention of migraines in children
-what is the centerpoint of tx?
-tx

A

-biobehavioral management (sleep hygiene, adequate duration of sleep, good sleep quality, improve fluid intake, eliminate caffeine, regular nutritional meals, exercise, stress management
-topiramate (ages 12-17); CBT; coenzymeQ10 and magnesium oxide

CMN568 (10 decks)

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