I'm rebuilding this site in a simpler format. Sorry that some of the pages are still unformatted.
CBTI Resources: ShutI now called “Somryst,” Sleepio, VA Sleep Coach App
Metoclopramide\r\n
Curbsiders #49 Vertigo and Dizziness is a good re-listen
summary at 78:18
Focus on timing and triggers, not on type!
Episodic triggered is triggered by Dix Hallpike
Episodic spontaneous Think TIA, or if long Hx, consider migraines or Menier's
For some Meniere's Dz, consider Gentamicin intra-tympanically
If unidirectional, send home with meclazine
Then refer to neurology
Compazine\r\n
Sumatriptan\r\n
Droperidol/Haloperidol
NSAIDs\r\n
Diphenhydramine\r\n
Dexamethasone helps prevent recurrence of migraine headaches, but should not be used in acute treatment.\r\n
Most patients with migraines do not respond favorably to treatment with opioids.
The use of hydromorphone as first-line therapy for acute migraine in the emergency setting is being questioned following results of a randomized trial that show prochlorperazine, a dopamine receptor antagonist, is overwhelmingly superior.\r\n
medscape.com/viewarticle/881723c
'), (256, 'The use of hydromorphone as first-line therapy for acute migraine in the emergency setting is being questioned following results of a randomized trial that show prochlorperazine, a dopamine receptor antagonist, is overwhelmingly superior.
medscape.com/viewarticle/881723
'), Migraine Prochlorperazine Twice as Effective as Opioid Hydromorphone for Acute Migraine in EDs medscape.com/viewarticle/881723 (322, 'Paraphasia is a type of aphasia. The substitution of a similar sounding word for another word is called paraphasia. With paraphasia, the words can also be jumbled.
If a patient is able to hear things and repeat them, it is called echolalia. With echolalia, the patient does not understand what he has heard. This is also referred to as echophrasia. Alexia is a type of aphasia. An aphasia in which there is a problem with reading is called alexia. Alexia is word blindness or text blindness. Alexia is also called optical aphasia or visual aphasia.
Apraxia refers to the condition in which a patient has difficulty performing motor acts, despite having the muscular capacity and coordination to do so. A patient with apraxia cannot execute the intended movement.
A writing disturbance is called agraphia. There are various forms of agraphia. With absolute agraphia, even simple letters cannot be written. This is also referred to as literal agraphia.
'),- How could this not be in the blueprint?\r\n
'), (357, 'Complex Regional Pain Syndrome (CRPS) is characterized by abnormal autonomic nervous system activity. CRPS often occurs in a limb and exhibiting vasomotor and neurologic symptoms out of proportion with objective findings. It often occurs following some type of event, such as a surgery, fracture, stroke, or myocardial infarction. Most of the time, there is no nerve lesion identified. CRPS is classified into 3 stages, and symptoms can vary depending on the stage. It is characterized by persistent burning and/or throbbing pain in an extremity. Swelling, redness, and increased hair/nail growth occur in stage I, and may progresses to cool, pale skin and even osteoporosis in the latter 2 stages. Allodynia, the phenomenon in which a normally painless stimulus produces significant pain response, is a common finding. No single exam finding or test is diagnostic of CRPS, which is a clinical diagnosis. Likewise, no single treatment approach is recommended.\r\n
There is no evidence that CRPS is an autoimmune disorder at this time.\r\n
When fracture is the inciting event, initiation of vitamin C following the fracture is associated with lower risk of CRPS. The reason is unknown.
movement disorder vocabulary\r\n
Huntington's disease is characterized by chorea and dementia. Clinical onset is usually between 30 and 50 years of age. Patients present with writhing choreiform movements of the body, which are not present in this patient.\r\n
Alzheimer's patients present with memory impairment and at least 1 of the following: language impairment, apraxia, agnosia, and impaired executive function. Rigidity and bradykinesia are primary signs; tremors are rare. These symptoms are not present in this patient.
\r\n
At the onset, the typical case of Guillain-Barre Syndrome (GBS) includes paresthesias and slight numbness in the fingers and toes. Clinically, the main sign is generally symmetrical weakness that evolves over several days to a week or two. In 5% of patients however, weakness progresses to rapid deterioration. Respiratory failure and total motor paralysis may occur within a few days.
\r\n
In Myasthenia Gravis, small motor units (such as ocular muscles) are most often affected, producing nystagmus. Major clinical features of this disease are weakness that improves after a period of rest and fluctuating fatigue, and these symptoms improve after administering acetylcholinesterase inhibitors. These symptoms are not present in this patient.\r\n
Speech and Language disorders\r\n
Amyotrophic Lateral Sclerosis (ALS)is a progressive bilateral muscle disease that causes fasciculations and hyperreflexia, plantar reflexes, and dysarthria. Sensation and bladder function remain normal.
\r\n
The common clinical presentation seen in multiple sclerosis is weakness, numbness, tingling, or unsteadiness in a limb; spastic paraparesis; retrobulbar neuritis; diplopia; disequilibrium; or a sphincter disturbance such as urinary urgency or hesitancy, which is not present in this patient.\r\n
Brain tumor. Symptoms of brain tumor vary by tumor location, but the headache tends to be worst in the morning and gradually increases in severity and frequency over time. Associated symptoms include vision changes, nausea, vomiting, sensory changes, confusion, and seizures.\r\n
Pseudotumor cerebri is a condition in which the intracranial pressure increases. The headache associated with pseudotumor cerebri typically is located behind the eyes and worsens with eye movement. Other associated symptoms include tinnitus, nausea, vomiting, dizziness, and changes in vision.
\r\n
A clinical triad of slowly progressive gait disorder, followed by impairment of mental function and sphincteric incontinence, highly suggests the presence of normal-pressure hydrocephalus. Ventricular expansion in hydrocephalus involves frontal horns, affecting the functions of frontal lobes and of basal ganglionic–frontal motor control. The central white matter is affected more than cortical gray matter, thalami, basal ganglia, and brainstem. The distortion of the central portion of the corona radiata by the distended ventricles affects the sacral motor fibers that innervate legs and the sacral bladder center, causing the abnormal gait and incontinence. Decreased inhibition of bladder contractions leads to the instability of bladder detrusors.\r\n
In cases of normal-pressure hydrocephalus, the formation of CSF equilibrates with absorption; there might be variations in the CSF pressure, but overall pressure is considered normal.\r\n
'), (326, 'Intention tremors are fine movements of the hands that are absent at rest, occur with activity, and worsen as the target is neared. They occur with multiple sclerosis and cerebellar disease.
Choreiform movements are brief, rapid, jerky, unpredictable motions of the hands. They occur both at rest and during normal actions. They are associated with both Huntington's and Sydenham choreas.
Asterixis is non-rhythmic flapping movements of the hands, especially if the wrists are dorsiflexed. It is associated with liver failure, renal failure, and pulmonary insufficiency.
Static, or resting, tremors are coarse movements of the hands that are present at rest, disappear with movement, and may involve alternation of the fingers in a \"pill-rolling\" manner. They are associated with Parkinson's syndrome and extrapyramidal dysfunction.
Postural tremors are fine movements of the hands that occur when the hands are held in an active position, usually against gravity. Examples of postural tremors are those resulting from anxiety, fatigue, and hyperthyroidism, as well as familial postural tremors.
'), (328, 'Static, or resting, tremors are coarse movements of the hands that are present at rest, disappear with movement, and may involve alternation of the fingers in a \"pill-rolling\" manner. They are associated with Parkinson's syndrome and extrapyramidal dysfunction.
Postural tremors are fine movements of the hands that occur when the hands are held in an active position, usually against gravity. Examples of postural tremors are those resulting from anxiety, fatigue, and hyperthyroidism, as well as familial postural tremors.
Intention tremors are fine movements of the hands that are absent at rest, occur with activity, and worsen as the target is neared. They occur with multiple sclerosis and cerebellar disease.
Choreiform movements are brief, rapid, jerky, unpredictable motions of the hands. They occur both at rest and during normal actions. They are associated with both Huntington's and Sydenham choreas.
Chorea is a spasmodic involuntary movement that involves the face and limbs. Chorea can be seen with Huntington's disease (Huntington's chorea).
Asterixis is non-rhythmic flapping movements of the hands, especially if the wrists are dorsiflexed. It is associated with liver failure, renal failure, and pulmonary insufficiency.
Asterixis is also called \"liver flap\". It is a flapping movement of the hands or arms. During the physical examination to test for asterixis, have the patient hold up his hands (dorsiflex) and spread his fingers. Asterixis is seen with metabolic encephalopathies.
Athetosis is slow, writhing, twisting involuntary movement. Almost all parts of the body can be affected by athetosis. Speech can also be affected when the athetosis is affecting the tongue. Depending on the characteristic of the movements that are seen, it is sometimes modified and called choreoathetosis or athetotic dystonia. Athetosis can be seen with cerebral palsy and some other conditions.
Ballism is a flailing, jerky movement of the limbs. It affects the proximal muscles. If the abnormal movement is on one side, it is called hemiballism.
Dystonia is an abnormal movement where there is abnormal contraction of muscles. Dystonia can be divided into primary and secondary. Spasmodic torticollis is a form of dystonia.
Cluster headaches typically present with severe unilateral pain lasting anywhere from 15 minutes to 3 hours. The “clusters” may occur multiple times daily and usually occur daily for weeks to months. Associated symptoms include nasal congestion, lacrimation, rhinorrhea, conjunctival erythema, miosis, ptosis, or anhidrosis on the affected side. Following a series of attacks, patients typically have remission of several weeks or even months.
During an attack, there can be discharge from the nose and eye on the same side of the face as the headache, a manifestation of autonomic dysfunction. Other symptoms include flushing, sweating, and Horner's syndrome. The pain of a cluster headache begins rapidly and is described as stabbing or knife-like. The heads last from only a few minutes to several hours.
Cluster headaches have a classic presentation of severe unilateral pain that lasts anywhere from 15 minutes to 3 hours. These \"clusters\" may occur once or multiple times daily, and they tend to occur daily for weeks to months. Attacks may be accompanied by nasal congestion, lacrimation, rhinorrhea, conjunctival erythema, miosis, ptosis, or anhidrosis on the affected side. Following a series of attacks, patients typically have remission of several weeks or even months.
Cluster headaches come in groups and attacks may be separated by months or years. There are 2 types: episodic and chronic. The patient is often a middle-aged man. Cluster headaches are characterized by excruciating, unilateral pain (stabbing sensation) often occurring in the ocular, frontal, or temporal areas. These headaches generally last for a period of 15 minutes to 3 hours, recurring at the same time of day. They typically occur during the night. Pain often radiates to the upper teeth, jaw, and neck. The pain is normally accompanied by 1 or more of the following: ipsilateral conjunctival injection or lacrimation; ipsilateral nasal congestion or rhinorrhea; ipsilateral eyelid edema; ipsilateral forehead and facial sweating; ipsilateral miosis or ptosis; and a sense of restlessness or agitation. Restlessness is one of the characteristic features of cluster headaches noted in patients; behaviors such as pacing or rocking the head and trunk with head in hands are common. Other symptoms of cluster headache include facial flushing or pallor, tenderness on palpation of the ipsilateral carotid artery, bradycardia, and tenderness of the scalp and facial areas. The absence of aura, nausea, or vomiting helps in distinguishing cluster headaches from migraines.
The treatment of choice for acute cluster headaches includes the administration of oxygen (7L per minute for 15 minutes), sumatriptan, or a combination of both. Other therapeutic measures include intranasal dihydroergotamine, intranasal capsaicin, or intranasal lidocaine. Prednisone and verapamil are often used in prophylaxis.
Migraine headaches tend to be associated with unilateral pain, but the attack typically lasts 4-72 hours.
Migraine headache. The typical presentation of migraine is moderate to severe pain that is often unilateral and described as throbbing. Pain is often accompanied by nausea, vomiting, photophobia, and phonophobia. A visual, auditory, sensory, or motor aura may occur with migraine but does not need to be present for diagnosis. Migraine headaches typically last 4 to 72 hours. A common migraine and classic migraine would not be associated with watery discharge from the nose and eye.
Common migraine is an intermittent syndrome characterized by hemicranial pulsatile cephalic discomfort, including nausea, vomiting, photophobia, anorexia, and phonophobia.
Classic migraine typically presents with an aura. It also includes features of nausea, vomiting, photophobia, anorexia, phonophobia, and a sense of just wanting to hide in a quiet dark room.
Tension headaches are less severe than cluster headaches. Patients usually describe the pain as a bilateral tightness sensation. The headaches are not usually associated with other symptoms.
Stress/tension headaches are a generalized type of headache precipitated by stress. They are not one-sided. They do not involve photophobia, nausea, vomiting, aura, or phonophobia. Tension headaches are usually bilateral and described more as a tightness sensation than throbbing. Tension headaches usually last only 30 minutes. Tension headaches are associated with stress. They are not be associated with watery discharge from the nose and eye.
Chronic daily headaches occur on a daily basis and are often disabling. This type of headache may be challenging to diagnose and treat. Headaches caused by medication overuse or drug rebound are the most treatable forms of refractory daily headache.
Brain tumors are associated with headaches, but they typically do not follow the above pattern. Headaches occurring with brain tumors may become more severe over time, and they usually do not resolve spontaneously.
'), (349, '
To determine the vessel involved, the site of the lesion must be determined. The sensory and motor homunculi are both located on the lateral surface of the cerebral hemispheres. Each half supplies the contralateral side of the body. From this, it is possible to determine that the area affected is on the lateral surface of the left cerebral hemisphere.\r\n
The motor and sensory homunculus are placed such that the lower half of the body is more medial and superior with the representation of the area below the knee extending onto the medial surface of the hemisphere. The left middle cerebral artery is responsible for motor function of the upper extremity and face; therefore, upper extremity weakness and facial plegia are present with infarctions in this territory. Lower extremity weakness may be present but is less prominent.\r\n
The left hemisphere is also the language side where connections exist among Wernicke's area, Broca's area, and the oral motor cortex. Both the Broca's motor area (area #44) and the Wernicke's area are in the area supplied by the middle cerebral artery on the lateral aspect of the hemispheres.\r\n
Involvement of the right anterior cerebral artery would result in motor and sensory function in the left lower extremity, sparing the hands and face.\r\n
Involvement of the left anterior cerebral artery would affect motor function in the right lower extremity but would spare the hands and face.\r\n
Involvement of the right middle cerebral artery would result in weakness of the upper extremity as well as facial plegia on the left side. Left lower extremity weakness may be present but is usually less pronounced.\r\n
Involvement of the left or right posterior cerebral artery results in visual deficits.\r\n
Although precise localization of neurologic deficits is often difficult, certain patterns are important to recognize. Brain stem involvement results in \'crossed findings\' (e.g., right facial weakness and left arm weakness) because the lesions affect the brain stem nuclei directly (uncrossed) and the corticospinal tract as it is crossing to the opposite side of the body. Because of the unique anatomic arrangement of the brainstem, a unilateral lesion within the structure can cause \'crossed findings\' in which ipsilateral dysfunction of 1 or more cranial nerves is associated with hemiplegia and hemisensory loss on the contralateral side of the body, as described in this case.\r\n
Medullary syndromes, such as lateral medullary syndrome, are associated with vertigo, nausea, vomiting, nystagmus as well as hiccups, and diplopia; they were not observed in this patient. Medial medullary syndrome is associated with tongue deviation toward the lesion, which is opposite to what is described in this case.\r\n
Cerebral (cortical) lesions produce contralateral motor and sensory findings in the limbs and contralateral cranial nerve deficits (e.g., right arm and right facial paralysis). Pontine lesions result in coma, miosis, gaze paresis, and altered respiratory patterns. Cerebellar lesions produce nystagmus, dizziness, nausea and vomiting, and the inability to stand or walk if midline cerebellar areas are involved.\r\n
'), (352, 'A seizure is defined as a discrete neurologic disorder in which there is excessive and synchronous discharge of cortical neurons. Epilepsy is a syndrome characterized by recurrent, unprovoked seizures. A seizure may be classified as generalized or partial. In a generalized seizure, there is bilateral cerebral hemisphere disturbance; in partial seizures, the abnormal neuronal discharge is limited to a specific brain area (e.g., right anterior temporal lobe). Generalized seizures may be primary (bilateral brain involvement at seizure onset) or secondary generalized (seizure starts in a focal brain area, then spreads to encompasses both cerebral hemispheres).
Valproic acid is usually the first-line medication for primary generalized seizures. It has a wide spectrum of action and is effective in most seizure types, including myoclonic seizures. It isn’t however recommended as the initial treatment in women of childbearing age because of its possible teratogenic nature.
Phenytoin and phenobarbital may also have a role in the treatment of primary generalized seizures, but valproic acid is superior. Phenytoin, phenobarbital, carbamazepine, and gabapentin have efficacy in partial and secondary generalized seizures.
'); (358, 'Ablation or destruction of the limbic areas highlights the role of limbic areas in the processing and storage of memory. Because of the protection afforded by the redundancy of having 2 hemispheres with overlapping functions, tumors, injuries or infarctions affecting limbic areas are often silent unless they cause pressure effects or electrical excitation. Toxic or metabolic damage, which typically affects symmetrical areas, can have a dramatic impact by contrast. The most common, clinically significant example is that of thiamine deficiency, which occurs in malnutrition, especially among alcoholics.
The feature that distinguishes Wernicke's encephalopathy, however, is \r\nophthalmoplegia, which reverses rapidly following intravenous infusion \r\nof thiamin.
Acute thiamine deficiency produces Wernicke encephalopathy. The cardinal features of this condition are delirium with ataxia, oculomotor dysfunction (especially 6th nerve palsy- intranuclear ophthalmoplegia), and sometimes anisocoria. Because thiamine is a cofactor for the cerebral metabolism of glucose, administering glucose to someone on the verge of thiamine deficiency can precipitate acute encephalopathy. Wernicke encephalopathy is prevented or rapidly reversed by administration of thiamine.
Chronic thiamine deficiency causes alcohol-induced persisting amnestic disorder (Korsakoff’s syndrome). The main sites of damage are paraventricular, symmetrical lesions in the mammillary bodies, the thalamus, and the hypothalamus. Lesions may also occur in the midbrain, pons, medulla, fornix, and cerebellum. Cerebellar and ocular signs may not be present. Diagnosis depends on a careful mental status examination. Patients with Korsakoff’s syndrome have relatively preserved long-term memory, are socially appropriate, use language normally, and can do simple calculations. Their profound recent memory loss seems so disproportionate to the rest of their mental status examination that observers may misdiagnosis malingering, i.e., willfully faking abnormality for personal gain. Patients with Korsakoff’s syndrome will occasionally try to conceal their deficits by confabulation, making up or agreeing to untrue scenarios given by the examiner. This is not the same thing as lying, but it is often mistaken for it. The mild macrocytosis is a common incidental finding in chronic alcoholics, but it does not account for the observed behavioral changes.
Get info from Curbsiders and from EM:RAP September
EmCrit podcast: Diagnosis of a Posterior Stroke show notes
Bottom line:
Don\'t try to differentiate between types. Don\'t ask whether they are spinning or the room is.
Do ask about triggers and timing
Organize into
A negative HINTS examination can rule out a stroke better than a \r\nnegative MRI with DWI in the first 24 to 48 hours after symptom onset \r\nwith a specificity of 96%.
I haven\'t watched this video yet, but need to HINTS:
I also need to check this out:
Types of shock\r\n
How metabolic alkalosis causes hypokalemia
\r\n
How metabolic alkalosis causes hypokalemia from joel topf on Vimeo.\r\n
'), (371, 'Posterior Stroke pages
https://emcrit.org/racc/posterior-stroke/
https://emcrit.org/racc/posterior-stroke-video/
https://www.uptodate.com/contents/evaluation-of-th...
http://www.60secondem.com/the-hints-exam/
https://wikem.org/wiki/EBQ:HINTS_Exam
To determine the vessel involved, the site of the lesion must be determined. The sensory and motor homunculi are both located on the lateral surface of the cerebral hemispheres. Each half supplies the contralateral side of the body. From this, it is possible to determine that the area affected is on the lateral surface of the left cerebral hemisphere.\r\n
The motor and sensory homunculus are placed such that the lower half of the body is more medial and superior with the representation of the area below the knee extending onto the medial surface of the hemisphere. The left middle cerebral artery is responsible for motor function of the upper extremity and face; therefore, upper extremity weakness and facial plegia are present with infarctions in this territory. Lower extremity weakness may be present but is less prominent.\r\n
The left hemisphere is also the language side where connections exist among Wernicke's area, Broca's area, and the oral motor cortex. Both the Broca's motor area (area #44) and the Wernicke's area are in the area supplied by the middle cerebral artery on the lateral aspect of the hemispheres.\r\n
Involvement of the right anterior cerebral artery would result in motor and sensory function in the left lower extremity, sparing the hands and face.\r\n
Involvement of the left anterior cerebral artery would affect motor function in the right lower extremity but would spare the hands and face.\r\n
Involvement of the right middle cerebral artery would result in weakness of the upper extremity as well as facial plegia on the left side. Left lower extremity weakness may be present but is usually less pronounced.\r\n
Involvement of the left or right posterior cerebral artery results in visual deficits.\r\n
Although precise localization of neurologic deficits is often difficult, certain patterns are important to recognize. Brain stem involvement results in \'crossed findings\' (e.g., right facial weakness and left arm weakness) because the lesions affect the brain stem nuclei directly (uncrossed) and the corticospinal tract as it is crossing to the opposite side of the body. Because of the unique anatomic arrangement of the brainstem, a unilateral lesion within the structure can cause \'crossed findings\' in which ipsilateral dysfunction of 1 or more cranial nerves is associated with hemiplegia and hemisensory loss on the contralateral side of the body, as described in this case.\r\n
Medullary syndromes, such as lateral medullary syndrome, are associated with vertigo, nausea, vomiting, nystagmus as well as hiccups, and diplopia; they were not observed in this patient. Medial medullary syndrome is associated with tongue deviation toward the lesion, which is opposite to what is described in this case.\r\n
Cerebral (cortical) lesions produce contralateral motor and sensory findings in the limbs and contralateral cranial nerve deficits (e.g., right arm and right facial paralysis). Pontine lesions result in coma, miosis, gaze paresis, and altered respiratory patterns. Cerebellar lesions produce nystagmus, dizziness, nausea and vomiting, and the inability to stand or walk if midline cerebellar areas are involved.\r\n
'),This video has been found to be
Notes from The Curbsider's podcast, episode #6: Become a Fibromyalgia and Chronic Pain Master, Part 1
Notes from The Curbsider's podcast, episode #7: Become a Fibromyalgia and Chronic Pain Master, Part 2
Drop the tender point exam. Instead use the new 2011 ACR Criteria to diagnose fibromyalgia
'), (202, 'Having your patients watch this video has been found to be as effective as medication.
Notes from The Curbsider's podcast, episode #6: Become a Fibromyalgia and Chronic Pain Master, Part 1
Notes from The Curbsider's podcast, episode #7: Become a Fibromyalgia and Chronic Pain Master, Part 2
Drop the tender point exam. Instead use the new 2011 ACR Criteria to diagnose fibromyalgia
'), (293, 'Having your patients watch this video has been found to be as effective as medication.\r\n
\r\nNotes from The Curbsider's podcast, episode #6: Become a Fibromyalgia and Chronic Pain Master, Part 1\r\n
\r\nNotes from The Curbsider's podcast, episode #7: Become a Fibromyalgia and Chronic Pain Master, Part 2\r\n
\r\nDrop the tender point exam. Instead use the new 2011 ACR Criteria to diagnose fibromyalgia\r\n
\r\n
\r\n
Consumer reports has drug reports designed for consumers that are pretty well made. CR: Fibromyalgia report (2014)\r\n
'), (198, 'add the two fibromyalgia podcasts and the youtube video by dr. clauw