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Chronic Pain Treatment: TCA’s, effexor, avoid narcotics Transient Global Amnesia
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Chronic PainTreatment: TCA’s, effexor, avoid narcotics Transient Global AmnesiaMigraine vs. vascular / 25% recur once, 3% chronic / no treatment other than possibly anti-platelet agents if you like the vascular hypothesis Concussion [NEJM] clinical state resembles transient global amnesia / concussion does not cause a loss of autobiographical information (this is more c/w hysteria or malingering); concussion-related amnesiacs do not confabulate Observation: at least 2 hours, up to overnight in hospital [table] Imaging: decide whether to obtain CT [table] post-concussion syndrome: headache (90%), dizziness, trouble concentrating in days-weeks-years following [table] Vertigo key point is to r/o brainstem/cerebellar strokeLasting > 24 hrsVestibular Neuritis peaks 1st day / resolves from week to months / 50% observe viral illness Romberg usu. fall or tilt toward side of lesion / can often be distinguished from stroke by associated nystagmus (pure vertical almost always means stroke, whereas horizontal and torsional can be both / nystagmus usu. remains in same direction when gaze changes and is suppressed by visual fixation)
may remain for days, usually improves within week of infarct / improvement for several months thereafter / can mimic vestibular neuritis by occurring without other symptoms of vertebrobasilar ischemia (diplopia, reduced vision, dysarthria, dysphagia, focal defects) / Romberg is variable Multiple Sclerosis (see other) can present with vertigo Lasting Hours or minutes Meniere’s isolated, severe vertigo (may have reduced hearing, tinnitus, pressure) followed by several days of dizziness / audiogram shows low frequency pure-tone hearing loss that fluctuates in severity Treatment: low salt diet, acetazolamide / antihistamines, anti-emetics, benzodiazepines may help with acute attacks / surgical decompression may be necessary in extreme cases TIA of vertebrobasilar system Migraine headaches Seizures (rarely, ‘tornado epilepsy’ from focal Sz of temporal lobe) Perilymph fistula (s/p otologic surgery) Lasting Seconds BPPV (benign paroxysmal positional vertigo) from debris in semicircular canal Findings: nystagmus or dizziness when quickly moved from sitting to lying position with head turned to one side (Nylen’s maneuver) / there should be no hearing loss, brainstem, cerebellar, or cranial nerve signs except N/V with severe episodes
Note: similar to vestibular neuritis, nystagmus is mostly unidirectional (horizontal or rotary) and does not change with direction of gaze; if vertical or changing with gaze think stroke Differential: hypothyroidism, AG or Lasix toxicity, stroke, trauma, Meniere’s labyrinthitis, acoustic neuroma Treatment: Eppley maneuver (takes just a few minutes, patient learns to repeat at home) / fixation on near object sometimes stops episodes CNS tumors Glial Cell Tumors Astrocytoma I Anaplastic astrocytoma II Glioblastoma multiforme III – butterfly glioma (spreads across midline) < 1 yr survival Treatment: radiation therapy with temozolomide Oligodendrogliomas – adults, slow, frontal lobes, calcifications Ependymomas – children, 4th ventricles, increased ICP Infratentorial – more in children Cystic cerebellar astrocytomas Ependymomas Medulloblastoma – vermis in kids, hemispheres in adults Meningioma – resection can be curative +/- radiation 30% of systemic CNS cancer spreads to lung, breast, melanoma, kidney, colon Increased ICP: N/V, headache (worse in am, diffuse), bilateral papilledema, personality changes, coma, generalized seizures, focal signs (sensory/motor) Ddx: bleed, neurodegenerative disease, abscess, AVM, meningitis, encephalitis, congenital hydrocephalus, toxic state Diagnosis: CT/MRI - MRI with gallidium is best for astrocytoma type I Treatment: +/- resection, +/- radiation, +/- chemotherapy, +/- steroids, +/- shunting Acoustic neuromas (CN VIII) usually presents with unilateral tinnitus, progressive hearing loss, not vertigo Spinal Tumors Mets from lung, breast, prostate Multiple myeloma, lymphoma Meningioma, neurofibromatomas Astrocytomas, ependymomas
Hunt & ? I mannitol, Dilantin / IV & V ventriculostomy (1st), surgery (2nd) Diagnosis: CT / 4 vessel angio Epidural Hematoma Middle meningeal artery / “honeymoon period” / unilateral dilated pupil (herniation), bilateral/fixed/dilated (impending respiratory failure, death) Treatment: burr hole, then craniotomy Subdural Hematoma Elderly, anticoagulation / Presentation: headache, drowsy (not so much seizures and papilledema) Spondylosis more cervical (C6 and C7) / protrusions of bone Presentation: progressive, glove-like distribution / limited neck extension, diminished reflexes Ddx: rheumatoid arthritis, ankylosing spondylitis, cervical rib, scalene anticus, carpal tunnel syndrome, ulnar nerve palsy, Pancoast tumor, primary CNS tumor of brachial plexus Diagnosis: plain film shows canal < 10 mm, decreased normal cervical lordosis / MRI for discs / CT for bones Treatment: neck immobilization, cervical traction, muscle relaxants / 95% improve without surgery (osteophyte resorption) / surgery: anterior cervical disc fusion, laminectomy (decompression) with progressive spondylotic myelopathy (may still recur) Disc Protrusion more lumbar (L5 and S1) / nerve root compression Presentation: radiating pain (sciatica), pain with straight leg raise (ipsilateral and contralateral), pain with direct palpation of nerve root, decreased ankle reflex, weakness of dorsiflexion Treatment: elective laminectomy for chronic pain / urgent laminectomy for foot drop and cauda equina syndrome (urinary retention, perineal numbness, bilateral sciatica) / Opinion: laminectomy is often only a temporizing procedure that may hasten spinal immobility Psychiatric Panic Attacks Incidence: 3% over lifetime Note: among postmenopausal women, panic attacks are relatively common, and may be an independent risk factor for heart disease and stroke. Ddx: thyrotoxicosis, hypoglycemia, pheochromocytoma, MVP (arrhythmia) Treatment: acute benzodiazepines, long-term TCA, SSRI Anorexia < 75% expected body weight / should be hospitalized / complications of refeedings (heart failure, abnormal LFT, low Mg and PO4 (so avoid TCAs with possibility of prolonged QT), no psychiatric medication has yet been shown completely effective in this disorder 1/07 Ophthalmology Inflammatory Conditions Conjunctivitis Discharge [pic][pic] Viral [pic] (HSV, adenovirus, others) Bacterial [pic][pic] (Neisseria, others) Other
hypopyon (pus in anterior chamber) [pic] Download 3.95 Mb. Share with your friends:
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