| Damage to multiple nerves. Mostly distal and symmetrical | Symmetric Polyneuropathy Definition |
| Diabetes, Alcoholism, Hypothyroid, B12 def, HIV, Lyme, Multiple Myeloma, Celiac, Sarcoid, Meds: Hydralazine, INH,Vit B6, arsenic and lead | What are the causes of Polyneuropathy? |
| First level test: B12, A1c, SPEP with immunifixation electrophoresis initially, TSH, CBC, and CMP. Extensive testing not necessary if known DM or ETOH
Second level test: EMG/NCS: EMG will differentiate between nerve or muscle disorder, NCS differentiates bw axonal or demyelinating neuropathy.
consider Lyme titer in Endemic area
CXR if suspect sarcoid | What is the work up of Polyneuropathy? |
| Radial neuropathy: Compression, DM or Lead toxicity | Acute Wrist Drop - Cause |
| Median N. Check TSH and Glucose
Treat: Splint, Steroid injection and Surgery | Carpel Tunnel : W/U and Tx |
| Weakness in leg, can't stand on toes, decrease sensation lower leg and absent ankle reflexes.
MRI | Sciatic N radiculopathy sx and w/u |
| Foot drop and inability to evert foot | Peroneal N sx |
| 7th CN ipsilateral paralysis half of face, loss of test, lacrimation and hyperacusis) Associated with viral illness and Lyme disease. 80% recover
Treat : Predinosine 60 mg taper for 7 days combined with Valacyclovir | Bell's palsy cause and treatment |
| CN 3 and 6 palsy( diplopia and ptosis/painful), foot drop, wrist drop, sensory polyneuropathy of distal LE | Neuropathy associated with DM |
| Pain and numbness in feet stocking distribution . Recovery with abstinence and MVI | Alcoholic Neuropathy sx |
| chemotherapy, H2 blockers, PPI, Metformin because lowers B12 absorption, Fluoroquinolones. | Which drugs are associated with neuropathy? |
| Treat underlying disease
First line: Amitriptyline or Duloxetine (less anticholinergic) follows by Venlafaxine
Gabapentin 100-300 mg tid
Alpha lipoid acid 600 mg/d as antioxidant
Topical lidocaine
Capsasin | What is the treatment of neuropathy? |
| POUND: 4/5
Pulsatile, phonophobia and photophobia
One day- can last up to 72 hours if untreated
Unilateral
Nausea
Disabling | Migraine Headache Dx |
| Tylenol 1000 mg
Asprin 900 mg
NSAIDS Ibuprofen 400 mg
Midrin ( isometheptne( sympathomimetic/ muscle relaxant) | Migraine Acute treatment mild to moderate |
| Sumatriptin 50-100 mg (max 200 mg) with Naproxen 500 mg
Dihydroergotamine nasal spray ( Migrant)
Midrin
Dexamethasone with Opiates and IV Reglan | Migraine Acute treatment : Severs Sx |
| Pregnancy,CAD, PAD, CVD, uncontrolled HTN, hemiplegic migraine, liver disease, SSRI
No not use more than 2x/wk due to rebound headache. | Whe to avoid Triptans |
| If having , > 2x wk, > 3 headaches/mo or using analgesics > 10x / mo
BB ( Propanolol)
TCA ( Amitriptyline)
SSRI (Fluoxetine, Mirtazapine and Venlafaxine) - caution with Tripan
Anticonvulsants ( Topomax, Gabapentin)
CaB ( Verapamil)
NSAIDS
Magnesium 400 mg/d and B2 and acupuncture and Botox | When do you use prophylactic medication for migraine? |
| MRI with and without contrast
Autonomic cephalgia: Severe supraorbital pain with lacrimation and nasal congestion.
Focal sign
Immunocompromised or over 50
Worst headache - R/O SAH with CT
Trauma
Cancer
Coumadin, Meth or Cocaine use | Red Flags for imaging Headaches |
| Tylenol, Aspirin, NSAID
For chronic: Amitriptyline or gabapentin or Botox | Treatment of Tension Headache |
| O2 7-12 L / 15 min
Sumatriptan 6 mg SQ
Zolmitripatan 5 mg intranasal
For chronic Rx Verapamil 240 mg/d or Prednisone 60 mg for 10 d. | Treatment of Cluster Headache |
| Unilateral periorbital with conjunctival injection and lacrimation
Occurs in clusters several times a day lasting minutes and for a few days.
Affects mostly men who smoke
Triggers: vasodilators, ETOH, NTG and histamine | Define Cluster Headache ( Trigeminal Autonomic Cephalgia) |
| Tender temporal a. with headache in pt > 55 y.o.
May be ass with PMR , Elevated sed rate
Treat Prednisone 60 mg taper 4 wk while awaiting bx.
Can lead to blindness | Temporal Arteritis Sx and treatment and complication |
| Worse headache of life associated with stiff neck.
Ass: LOC, sentinel headache 3 wk before
W/U: CT and if - , LP
Cause : Saccular aneurysm in circle of willis | SAH Sx |
| Headache > 15 day/mo | Definition of Medication Overuse Headache |
| Chroni pain, Obesity, DM, and Arthritis | What are the risk factors for Medication overuse headache? |
| Central sensitization and neuronal dysfunction causing inappropriate response to stimuli. Lowers threshold for pain. Pain lingers after removal of trigger. | What is the pathofiz of medication overuse headache? |
| Topiramate, Amitriptyline and Steroids 60 mg taper for withdrawal
Slowly withdrawal the medication while starting prophylactic
Acute Rx during taper: Hydroxyzine, Reglan or Gabapentin | What is the treatment of overuse headache? |
| Pregnancy, CAD, PVD, uncontrolled HTN, SSRI, MOI, liver disease and hemiplegic migraine
Avoid taking > 2x/wk due to rebound headache. | When do you avoid Triptans? |
| Avoid estrogen contains contraceptives,. Doubles the risk of stroke. | Migraine with Aura - Contraceptive |
| Functional impairment with normal CT. Affects physical, cognitive, emotional and behavioral domains. | Concussion Definition |
| Glasgow Coma Scale : Eye opening4, Verbal response5 and motor response6. 15 best. | Concussion - classification |
| May be delayed: Headache, confusion, amnesia, dizziness, N/V, balance, confusion, disorientation.
Later: mood and cognitive disturbance, sensitivity to light and noise seep. | Concussion sx: |
| Most sx resolve in 2 wk. Children have delayed recovery up to 3 mo. | Concussion prognosis: |
| Seizure < 5% if mild, Epidural hematoma with bleed, second impact syndrome 50% mortality, post concussion syndrome ( prolonged sx)
If sx > 1 mo refero out | Complication of concussion. |
| SCATS 5 | Tool for concussion assessment in athletes |
| Neck pain or tenderness
Double vision
Weakness or tingling in extremities
Severe or worsening headache
LOC
Seizure
Deteriorating conciousness
Vomiting and Agitation. | Red Flags for Concussion |
| LOC, amnesia, disorientation severe headache, MS change, abnormal neurological, seizure, GCS < 15, suspect fx, vomiting, over 65, retrograde amnesia > 30 min, MVA, fall > 3 ft. | When do you image for concussion with CT? |
| 48 hours physical and cognitive rest, sunglasses for photophobia and ear plugs for photophobia
Tylenol for pain. NO NSAIDS
ED precautions
Monitor for ups to 3 mo. | Management of Concussion |
| Neuro: Balance with Romberg and gait
CN, DTR, muscle strength, finger to nose and MS exam. | Concussion Eval |
| Head trauma, Drug withdrawal ( ETOH) or use ( Tramadol, amphetamine) , sleep deprivation, Elyte abnormality ( hypoglycemia, Mg, CA, Na)
Anoxia, infection, stroke 22% in elderly. | Seizure: Causes |
| Labs: CMP, Mg, CBC, Tox screen, CPK
EEG: if abnormal increase risk of subsequent seizure 50%
MIR to r/o structural brain lesion. | Seizure Eval |
| Not needed if first seizure with provoking factors
Antiepileptic drugs: Topomax, Lamotrigine, Valproate
Avoid TRamadol, Wellbutrin, TCA, Sympathomimetics, and some antipsychotics. | Seizure treatment: |
| 2-4 years if seizure free and normal EEG
Risk of seizure recurrence off ACE 25%
Driving: need at least 12 mo seizure free interval | The can you stop AED ( Antiepileptic Drugs) |
| Artharitis, and disc disease | Spinal Stenosis causes |
| Bilateral pain LE brought on by walking and standing upright.
Relieved by bending forward
Exam can be normal. | Spinal Stenosis symptoms |
| Weakness in arms and legs, sensory loss, urine and rectal sphincter dysfunction with incontinence, Lhermitte's sign (electric shock sensation with neck flexion. ) | Sx of myelopathy |
