Tx cluster HA
Ergotamine, methylsergide, lithium, prednisone
Tx tension HA
Stress reduction (tx underlying cause)
NSAIDs, Tylenol, ASA
Aura in what kind of migraine?
Common doesn’t have aura
Acute: NSAIDs Tylenol Serotonin receptor agonist. (DHE) Sumatriptan (limit use of)
TCAs (amitryptyline) - S/E constipation
Tx menstrual migraines
Absolute contraindication to ECT
Ok with pacemakers, cardioverter-defibrilators, preggers, elderly
The mechanism of the syncope seems to be
a period of high sympathetic tone (often induced by pain or fear),
followed by sudden sympathetic withdrawal,
which then triggers a paradoxical vasodilatation and hypotension.
Dementia w/ Lewy Bodies
parkinsonian symptoms (rigidity, tremor), fluctuating levels of alertness and cognitive abilities, behavior sometimes mimicking acute delirium. Significant visual hallucinations are common,
delusions and auditory hallucinations are seen to a lesser degree.
Med for migraines NOT ok in preggers
have the potential to cause vasoconstriction of the placental and uterine vessels
should be used only if the benefit clearly outweighs the harm
What S/E from neuroleptics respond to tx w/ beta blockers
Akathisia (motor restlessness and inability to sit still)
Can also use anti-ACh
Preventing spread of meningococcal disease when susceptibility of org is not known
Meningococcal vaccines no help b/c protective effects take too long and only for group B
A post-traumatic air-fluid level in the sphenoid sinus is associated with
basilar skull fractures
is characterized by the sudden onset of headache and hypertension in a patient with a lesion above the T6 level.
There may be associated bradycardia, sweating, dilated pupils, blurred vision, nasal stuffiness, flushing, or piloerection.
It usually occurs several months after the injury and has an incidence as high as 85% in quadriplegic patients.
Frequently, it subsides within 3 years of injury, but it can recur at any time.
Bowel and bladder distention are common causes.
Contraindications for thrombolysis in acute stroke
> 3hrs after onset of deficit
blood glucose levels 400 mg/dL,
resolving transient ischemic attack
hemorrhage visible on a CT scan
The goal of therapy in migraine prophylaxis is a reduction in the severity and frequency of headache by 50% or more.
amitriptyline, propranolol, timolol divalproex sodium topiramate
Nightmares occur when? Sleepwalking?
Nightmares occur in the second half of the night, when rapid eye movement (REM) sleep is most prominent.
Parasomnias, including sleepwalking, confusional arousal, and sleep terrors, are disorders of arousal from non-REM (NREM) sleep.
Only FDA approved antidepressant for kids
Contraindications to ECT
But more complications are seen in patients with a history of recent cerebral hemorrhage, stroke, or increased intracranial pressure
antipsychotic of choice in patients with dementia associated with Parkinson’s disease
Best tx for anorexia in adolescent
Ppx altitude sickness
Dexamethasone (for sulfa allergy)
Unipolar depression and incomplete response to therapy. What is a good adjuvant therapy?
lithium or low-dose T 3
atypical antipsychotics don’t work as well
Tx cerebral malaria
intravenous quinidine gluconate
Apraxia is a
transmission disturbance on the output side, which interferes with skilled movements. Even though the patient understands the request, he is unable to perform the task when asked, but may then perform it after a time delay.
Agnosia is the
inability to recognize previously familiar sensory input, and is a modality-bound deficit. For example, it results in a loss of ability to recognize objects.
Which antidepressant is good for old people with insomnia and weight loss?
Mirtazapine has serotonergic and noradrenergic properties and is associated with increased appetite and weight gain.
It may be particularly useful for patients with insomnia and weight loss.
Tx essential tremors
Best initial tx PTSD
- are able to reduce all three clusters of PTSD symptoms.
MAOIs are not first line
- moderate to good improvement in reexperiencing and avoidance symptoms, but little improvement in hyperarousal
essential features of the diagnosis of dementia are
memory loss and impairment of executive function
Patients rarely report mem- ory loss; the informants are usually their family members
Most common cause of dementia
Criteria to dx Alzheimer’s
Development of multiple cognitive deficits manifested by both memory impairment and one of the following:
The deficits above are a decline from previous functioning and cause significant impairment
in social or occupational functioning.
The course is of gradual onset and continuing decline.
The deficits are not due to other central nervous system, systemic or substance-induced
conditions that cause deficits in cognition.
The disturbance is not accounted for by another psychiatric diagnosis.
Common causes of dementia like symptoms in elderly
Vit b12 deficiency
What is recommended by the American Academy of Neurology for the routine evaluation of dementia?
A noncontrast head CT or MRI
Migraine headaches - what suggests dx?
moderate to severe headache with a pulsating quality;
nausea and/or vomiting;
worsening with activity;
multiple attacks lasting for 4 hours to 3 days; absence of history or physical examination findings that would make it likely that the headache is the result of another cause
Typically presenting with pericranial muscle tenderness and a description of a bilateral bandlike distribution of the pain
Unilateral headaches that may have a high male predominance, can be located in the orbital, supraorbital, or temporal region.
It is generally described as a deep, excruciating pain lasting from 15 minutes to 3 hours.
These headaches are usually episodic; however a small subset may have chronic headaches.
most prevalent form of primary headache disorder
Tx tension headache
aspirin, acetaminophen, and NSAIDs.
Ppx tension headache
In frequent headache sufferers, the combination of antidepressant medications and stress management therapy reduces headache activity significantly.
calcium channel blockers and β-blockers.
Tx cluster headache
100% oxygen at 6 L/min,
Ppx cluster headache
Verapamil, lithium, divalproex sodium, methysergide, prednisone
TIA vs stroke vs RIND
TIA is defined as a focal neurologic deficit lasting less than 24 hours. Most TIAs last for less than 1 hour.
A stroke is presumed to have occurred if the symptoms persist for more than 24 hours.
A residual ischemic neurologic deficit (RIND) is defined as a neurologic deficit of greater than 24 hours and less than 3 weeks.
What is the single most important risk factor for stroke
Tx HTN in stroke
Tx if SBP is > 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg.
Unless a hypertensive encephalopathy, aortic dissection, acute renal failure, or pulmonary edema is present, the treatment of arterial hypertension should be cautious
IV labetalol, nicardipine, and sodium nitroprusside
tPA if not hemorrhagic and within 3 hrs
The occurrence of stroke after TIA is
as high as 5.3% within 2 days and 10.5% within 90 days
Management of stroke after it happens
Patients with stroke but no detected sources of embolism benefit from antiplatelet agents, not anticoagulants.
Aspirin, clopidogrel, or a combination of aspirin and dipyridamole are acceptable regimens.
For patients with recent TIA or ischemic stroke and ipsilateral severe (>70%) carotid artery stenosis, carotid endarterectomy is recom- mended. When the degree of stenosis is less than 50%, there is no indi- cation for CEA.
Patients with a history of symptomatic cerebrovascular disease should be treated to an LDL goal of less than 100 mg/dL.
NSAID S/E w/ propensity to produce more central nervous system adverse effects than other NSAIDs
Pseudotumor cerebri imaging on CT
CT is usually normal or shows small ventricles.
The cardinal physical signs of Parkinson’s
distal resting tremor, rigidity, bradykinesia, postural instability, asymmetric onset.
dopamine receptor blockers haloperidol and pimozide
α-receptor agonists clonidine and guanfacine are effective for treating mild tics
There is currently no treatment available to slow the progression of disease.
The chorea can also be treated with reserpine, tetrabenazine, and clonazepam.
The chorea does respond favorably to haloperidol and fluphenazine, though such treatment often makes voluntary movements worse.
Antidepressant less likely to gain wt?
And gain wt?
Bupropion is the antidepressant least likely to cause weight gain, and may induce modest weight loss.
Among SSRIs, paroxetine is associated with the most weight gain and fluoxetine with the least.
Mirtazapine has been associated with more weight gain than the SSRIs.
How to establish a prognosis in a comatose patient after a cardiac arrest.
The duration of CPR is not a factor,
the absence of pupillary and corneal reflexes, as well as motor responses to pain, are not reliable predictors before 72 hours.
Myoclonic status epilepticus at 24 hours suggests no possibility of a recovery.
Tx generalized anxiety disorder
Progressive supranuclear palsy
is characterized by early falls, vertical (especially downward) gaze, axial rigidity greater than appendicular rigidity, and levodopa resistance.
Initial tx of status epilepticus?
Lorazepam, 0.1–0.15 mg/kg intravenously, should be given as anticonvulsant therapy after cardiopulmonary resuscitation.
This is followed by phenytoin, given via a dedicated peripheral intravenous line.
Fosphenytoin, midazolam, or phenobarbital can be used if there is no response to lorazepam
Dystonia can be caused by any agent that
blocks dopamine, including prochlorperazine, metoclopramide, and typical neuroleptic agents such as haloperidol.
The acute treatment of choice is diphenhydramine or benztropine.
can be difficult to differentiate from cervical radiculopathy, shoulder pathology, and cerebrovascular accident.
The pain preceded the weakness, no trauma was involved, and the weakness is in a nondermatomal distribution, making brachial neuritis the most likely diagnosis.
Electromyography is most likely to show this lesion, but only after 3 weeks of symptoms.
Atypical antipsychotic that won’t cause as much wt gain
Antipsychotics causing wt gain
Second-generation, or “atypical,” antipsychotics are associated with weight gain, elevated triglycerides, and type 2 diabetes mellitus. Olanzapine and clozapine are associated with the highest risk.
How do tell pseudoseizure vs seizure
obtained within 20 minutes of the event, a serum prolactin level may be useful in differentiating a true seizure from a pseudoseizure.
An elevated level has a sensitivity of 60% for generalized tonic-clonic seizures and 46% for complex partial seizures.
Other features suggestive of seizure activity include tongue biting, the presence of an aura, postictal confusion, and focal neurologic signs.
The workup of patients with syncope begins with a history and a physical examination to identify those at risk for a poor outcome. Then….
In most cases, the recommended test is an EKG.
Patients who have a prodrome of 5 seconds or less may have a cardiac arrhythmia.
Patients with longer prodromes, nausea, or vomiting are likely to have vasovagal syncope, which is a benign process.
Patients who pass out after standing for 2 minutes are likely to have orthostatic hypotension.
What is most effective in depressed older patients.
What herb is assoc w/ serious intracerebral bleeding?
Which antidepressant has less sex side effects
Motor side effects of the antipsychotic drugs can be separated into five general categories:
dystonias, parkinsonism, akathisia, withdrawal dyskinesias, and tardive dyskinesia.
Akathisia is a syndrome marked by motor restlessness. Affected patients commonly complain of being inexplicably anxious, of being unable to sit still or concentrate, and of feeling comfortable only when moving.
- characterized by obsessive thoughts and compulsive behaviors that impair everyday functioning.
- second line: risperidone, clonazepam
How decrease the risk of postherpetic neuralgia from zoster?
Give famciclovir/ acyclovir/valcyclovir within 72 hrs of herpes zoster presentatio
In the geriatric population, what is the most common cause of seizures?
- 10% of stroke victims developing epileptic seizures.
- Seizures are more common following hemorrhagic strokes compared to nonhemorrhagic strokes
What are the most appropriate first-line pharmacologic treatment for depression in nursing-home residents.
Causes of serotonin syndrome
Sx: mental status changes, agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination, and fever
MAOIs tramadol, sibutramine, meperidine, sumatriptan, lithium, St. John’s wort, ginkgo biloba, atypical antipsychotic agents.
Childhood simple febrile seizure
- finding a source for the fever; this should include a lumbar puncture if meningitis is suspected.
most common infections:
- viral upper respiratory infections,
- otitis media,
–>Phenytoin and carbamazepine are ineffective for febrile seizures. Phenobarbital is sometimes used for prevention of recurrent febrile seizures, but is not indicated as an initial therapy.
The most appropriate initial pharmacologic treatment of panic disorder is
Which SSRI has less CYP 450 inhibition?
Tx prepratry grief in dying pateitn
Live a few days - methylphenidate
Longer - SSRIs
Antipsychotics w/ S/E hyperglycemia
Tx depression adn insomnia
Trazodone + antidepressant
Amitriptyline can be used but not in someone with cardiac arrhythmia