who is at high risk of delirium during hospitalization?
elderly pts with dementia
medical indications for catheter
relieve urinary retention
monitor fluid status in acutely ill pts
pts with stage 3/4 pressure ulcers on butt
- aside of these indications, remove urinary catheter to prevent things like infection and delirium
which sedatives should be avoided in elderly?
benzodiazepines and diphenhydramine
- can precipite delirium
pt post-op presents with acute, fluctuating mental status changes with difficulty focusing or maintaining attention and disorganized thinking
think of delirium
patients with chronic dementia are at great risk of what after surgery with general anesthesia?
delirium
recommended therapy for delirium in the ICU when supportive care is insufficient?
antipsychotic agents - haloperidol
pt presents with mental status changes, nystagmus, opthalmoplegia and unsteady gait - what should you consider?
Wernicke encephalopathy - due to thiamine deficiency
conditions assoc with Wernicke encephalopathy
AIDS, alcohol abuse cancer hyperemesis gravidarum prolonged TPN post-surgical status glucose loading
cognitive impairment with fluctuating lethargy/inattention, hallucinations and asterixis implies..
toxic encephalopathy - ie. medication induced delirium
what types of drugs can provoke delirium in a elderly pts with mild cognitive impairment, early dementia of Parkinson’s disease?
anticholinergic drugs (ex. nortriptyline)
migraine with aura consists of..
neurologic abnormalities including visual loss, hallucinations, numbness, tingling, weakness or confusion (diffuse symptoms)
aura associated with partial seizures is characterized by..
feeling of deja vu, rising epigastric sensation or autonomic disturbances; automatisms (lip smacking) can also be suggestive of partial seizure
pt presents with a headache that is dull, bilateral or diffuse described as a pressure or squeezing sensation; the pain is usually not disabling
tension headache
chronic daily headache
headache is present on > 15 days/month for at least 3 months
disabling headache assoc with tearing or rhinorrhea; typically unilateral and periorbital/temporal
cluster headache
- cluster episodes usually last 6-8 weeks with remission lasting 2-6 months
what is a cluster headache classically assoc with?
lacrimation rhinorrhea/nasal congestion eyelid edema facial/forehead sweating miosis/ptosis
common visual symptoms associated with migraine
perceptions of flashes of light
arcs of flashing light that forms zig-zag pattern
area of loss of vision surrounded by normal visual field
work-up order for “thunderclap headache” as in subarachnoid hemorrhage
- CT scan without contrast - if neg,
- do lumbar puncture, - if neg,
- CT or MR angiography
prophylactic tx. of migraine headaches
pt should have 2+ headaches per week
first line - propranolol
- can also use: amitriptyline, valproic acid, topiramate, other BB, petasites hybridus
dementia characterized by prominent memory loss, anomia, constructional apraxia, anosognosia (impaired recognition of illness) and personality change
Alzheimer’s dementia
dementia the progresses over months and startle myoclonus; also: visual/cerebellar disturbance, pyramidal/extrapyramidal dysfunction and akinetic mutism
Creutzfeld Jakob disease
dementia accompanied by Parkinsonism, visual hallucinations and fluctuating symptoms; MC includes impaired learning and attention, psychomotor slowing and visuospatial impairment (vs. memory)
Dementia with Lewy Bodies
pt presents with behavioral and personality changes ranging from apathy to social disinhibition and emotional lability - dementia?
frontotemporal dementia
stages of dementia based on MMSE
MMSE 21-25 = mild dementia
MMSE 11-20 = moderate dementia
MMSE 0-10 = severe dementia
first line initial therapy for mild-moderate Alzheimer’s dementia
Ach-esterase inhibitors: donepezil, rivastigmine or galantamine
first line tx of moderate to advanced Alzheimer dementia
memantine
- better effects when added to donepezil
what types of drugs are implicated in acute dystonic reactions?
neuroleptic, antiemetic and serotonergic agents - dystonic reactions typically occur w/in 5 days of initiating therapy
pt presents with resting tremor, bradykinesia, rigidity and postural instability
Parkxtinson’s disease
upper extremity, high frequency tremor present with both limb movement and sustained posture of the involved extremities and is absent at rest; usually bilateral
essential tremor
- usually improved with alcohol and worsens with stress
first line therapy of essential tremor
propranolol
- others include: primidone, gabapentin, topiramate
CSF findings in viral meningitis
lymphocytic pleocytosis
glucose > 45
protein < 200
negative gram stain
which serogroup of meningococcus does the vaccine not protect against?
serogroup B
clues to diagnosis of RMSF?
headache, fever, myalgia, abdominal pain
rash begins on wrists and ankles
thrombocytopenia, leukopenia and elevated transaminases
infection in spring/early summer
CSF and blood cultures with gram positive diplococci
strep. pneumo meningitis
empiric tx. for bacterial meningitis
vancomycin
ampicillin
ceftriaxone
- adjunctive tx. with dexamethasone
what is the recommended strategy for reducing complications after acute stroke?
early mobilization with physical and occupational therapy
tx. of ischemic stroke w/in 3 hours of presentation
thrombolysis with tPA
- if not eligible for tPA, give aspirin or clopidogrel
threshold for acute BP lowering in pts with acute stroke who are eligible for thrombolysis
185/110 mmHg
- use IV labetalol or nicardipine
threshold for BP lowering in pts with acute stroke
IV labetalol or nicardipine if SBP > 220 mmHg or diastolic < 120 mmHg
(or manifestations of end organ damage)
Tx. of subarachnoid hemorrhage
surgical clipping of aneurysm with cerebral angiography w/in 72 hours of onset
in whom are sumitriptan and other triptan drugs C/I in?
pts with stroke and uncontrolled HTN
findings in Bell’s palsy
complete facial neuropathy impairing the entire hemiface, including foreheard corrugators which are spared by cerebral lesions
Bell phenomenon
reflexive rolling upwards of the globe during eye closure
sensory loss and limb weakness beginning in LE and moving up with absent deep tendon reflexes
Guillain-Barre
electromyography result in Guillain-Barre
demyelinating polyradiculoneuropathy
CSF findings in Guillain-Barre
albuminocytologic dissociation - spinal fluid cell count is normal but spinal fluid protein level is elevated
Tx. of Guillain Barre
IVIG and plasma exchange
aching wrist pain, numbness and tingling in median nerve sensory distribution of fingers and weakness of thenar muscles; usually worse at night
Carpal tunnel syndrome
pain elicited by flexing the thumb into the palm, closing fingers over thumb and bending wrist in ulnar direction (Finkelstein test)
painful in de Quervain tenosynovitis
- tenderness in anatomic snuffbox
synovia filled cysts arising from joints or tendon sheaths that typically appear on dorsal hand or ventral wrist
Ganglion cyst
- usually compress other structures and cause pain
Guyon tunnel syndrome
ulnar nerve compression
loss of sensation in a stocking glove distribution that is associated with paresthesias or painful dysesthesias
diabetic neuropathy
