Neuro
A key piece of CNS exam
Fundoscopic exam
Nocturnal seizures, focal/face, activated by drowsiness
What are Benign Rolandic Seizures -
AKA: childhood epilepsy with centrotemporal spikes
typically in ages 3-13 year olds
Begins with onset of menses and ends with ovulation
What is the Follicular phase of the menstrual cycle
Remember the physiology -
Corpus luteum from previous cycle involutes --> decreased levels of estradiol and progesterone --> release of GnRH
(gonadotropin-releasing hormone) --> increased levels of LH and FSH
Muscle aches
High fever
Rash
What is-
The NP should ask about RECENT TRAVEL - and specifically where and if outside of the US
Based on these answers you can develop a DDX
If travel is to Africa - Lyme and Rocky mountain spotted fever would be less likely
Based on symptoms and travel location to Africa - Dengue and Chikungunya should be high on your DDX list
Occult bacteremia: febrile child, URI or
GI sxs, maculopapular rash.
What are a degree of Meningococcal Disease and the manifestations
Many resolve without tx but 66% of cases
progress to meningococcal meningitis.
Different degrees of illness -
occult bacteremia
Meningococcemia-fulminant type progresses
RAPIDLY over several hours starting with fever, septic shock sxs, h/a, myalgia, chills, cold hand/feet,
petechiae. Death can occur(within 12 hours of onset)!
Meningococcal meningitis- fever, h/a, stiff neck. Irritability and fever may be only sxs in infants and young children.
As the PNP you know the diagnostic work up would include-
1) Positive culture or Gram stain
2) Blood, CSF**, sputum
3) Blood and CSF may be negative if partially tx
with abxs
4) PCR- results in 4-8 weeks
5) Other lab findings: leukopenia or leukocytosis
with inc bands and neutrophils,
hypoalbuminemia, hypocalcemia, metabolic
acidosis, elevated lactate, elevated ESR and
CRP, decreased PT, fibrinogen and prolong
coag time
At least 2 unprovoked (or reflex) seizures occurring > 24 hours apart
One unprovoked seizure and the probability of further seizures
What is the definition of Epilepsy
4-8 month old with cluster of flexor/extensor spasms, common upon waking
What are Infantile spasms (West Syndrome)
Triad of West Syndrome: Infantile spasms, hypsarrhythmia, MR
ID's and treated early - better outcomes
Begins with ovulation – ends with menstruation
What is the Luteal phase - this is known as the most constant phase
CBC with differential
Comprehensive metabolic panel
Protein level
What labs would you order as the NP seeing a child with a prolonged high fever, retroorbital pain and morbiliform rash
You would expect the results to be based on the symptoms and suspected diagnosis:
Decreased protein
decreased platelet count
elevated hematocrit
Spread by bite of female Anopheles
mosquito infected with one of five types
of the parasite Plasmodium
What is Malaria.
Malaria - Seen mostly in subtropical areas, Africa -
SO ASK ABOUT TRAVEL!!
Is seen in the USA most cases are due to "hitchhiking mosquitos" with travelers from endemic areas.
Some common findings to be aware of are:
• Anemia
• Thrombocytopenia
• Elevated bilirubin
• Aminotransferases elevated
Of note - if you have the capability - Diagnosis can be made by identifying parasite microscopically
REFER to the red book and CDC sites for most up to date treatments and outbreaks
For example - if you see a patient with a fever, chills, headache on and off for the past three weeks. You should consider a smear to look for plasmodium to rule out Malaria and keep this in your ddx when identifying symptoms and recent travel
Biofeedback, Adequate sleep, Healthy diet, Exercise
What are nonpharmacological therapies for headache management
EEG with no activity but patient having active movement on clinical exam
What is the description of Psychogenic Non-Epileptic Seizures
Paroxysmal non-epileptic events that are not associated with EEG changes
A real condition that is thought to be a response to stress, non-intentional, less likely to have incontinence with event
Painful menstruation in the absence of pelvic pathology
What is Primary Dysmenorrhea
This accounts for ~ 90% of dysmenorrhea (cause of...)
Remember:
Primary dysmenorrhea begins when adolescents attain ovulatory cycles
Within 6-12 months of menarche (ACOG, 2019) - some say 1-2 years
PATHO – hyperactivity of the myometrium with accompanying uterine ischemia – considered to
play a significant role in pain.
Prostaglandins = increase myometrial hyperactivity
◦ During the cycle Prostaglandins -->cause uterine contraction to expel the lining -->Elevated levels of PG increase contractions and compress surrounding vessels -->cuts off oxygen to the tissues --> PAIN and CRAMPING --> which is often the presenting symptom patients will admit or present with.
Most concerning TB medication adverse reaction?
Vomiting, jaundice
Although there may be many other side effects of TB treatment - you would instruct your patient to go to the ED for vomiting and jaundice over less complex side effects that you would educate them about such as joint pain, fatigue, bruising.
If they are on isoniazid you would educate them on vomiting and jaundice. If they are on rifampin you would educate them on itching and that it turns urine, saliva and tears orange.
Epstein Barr Virus
What is the most common cause of Infectious Mononucleosis.
Can also be caused by CMV - so consider this if EBV titers are negative or indicate a "past infection"
carbamazepine, gabapentin, oxcarbazepine, phenobarbital, phenytoin, and Ethosuximide
What are narrow spectrum medications for seizures
Focal seizures - carbamazepine, gabapentin, oxcarbazepine, phenobarbital and phenytoin
CAE (Absence) seizures - Ethosuximide
Documented headache over 3 or more consecutive cycles, occur exclusively on day 1+/-2days
In at least 1 out of 3 menstrual cycles and no other time of the cycle
What is a Menstrual Migraine
Different from a menstrually related migraine that occurs additionally at other times of the cycle
In pure menstrual migraine without aura hormone therapy is more likely to be effective
Inhibit the production of prostaglandins --> decrease cramping --> decrease pain
What are NSAIDS
What is Zika -
Remember:
• Zika transmits to humans mainly through the bite of an infected Aedes species mosquito
• The mosquito vectors usually breed in domestic
water-holding containers
They bite mainly during the day so this is a key education piece to share with families as most other mosquitos bite at dusk.
The CDC is a great resource for tracking Zika outbreaks domestically and when you have patients that are traveling
sore throat
Most common symptom of IM in 16-20 year olds Remember - younger children can have EBV IM and typically have mild symptoms.
IM is a self-limiting infection that can last weeks to months and is highly contagious
Headache diary and lifestyle modifications
Individualized approaches to headache management
Naproxen, Ibuprofen, Acetaminophen, Excedrine migraine
What are first-line abortive medications for headaches/migraine after nonpharmacological
Characterized by depressed or labile mood, anxiety, irritability and anger occurring exclusively during the 2 weeks preceding menses
vs
A group of physical, cognitive, affective and behavioral symptoms that occur several days to 1-2 weeks before menses
What is PMDD vs PMS
PMDD-
The symptoms must be severe enough to interfere with functioning (school/occupational/social)
• A distressing and disabling condition that requires treatment (unlike the more common PMS)
• DSMV – established 5 criteria for the diagnosis of PMDD
PMS- characterized by the following:
Recurrent during the luteal phase of the menstrual cycle
• Resolves within 4 days after the onset of menstruation
• Variable but significant severity that can result in deterioration of interpersonal relationships and normal activity
Important for the PNP to remember that there is a screening tool that we can use -
The PSST- A Validated tool that scores the severity of premenstrual symptoms
Infectious 2 days prior to onset of
Patients can have symptoms, during 7 days of viremia and the incubation period is 3-14 days
What is Dengue Fever -
This is a RNA virus transmitted from infected mosquitoes
One way humans can transmit the virus is through
blood.
There are 3 phases - Febrile, Critical and Recovery - all present differently -
Febrile phase: Fever (> 102.2) PLUS headache,
retroorbital pain, photophobia, body
aches, joint/muscle pain, facial flushing,
morbilliform rash, infected pharynx,
leukopenia, anorexia, n/v, epistaxis,
ecchymosis, bleeding
Remember - Early diagnosis and mgmt. are KEY
• Supportive care- IV fluids, antipyretics,
monitor for bleeding
• Admit for deteriorating condition
• Complications: myocarditis,
pancreatitis, hepatitis, neuroinvasive
disease
HHV4
what is the EBV - a member of the herpes family
It persists as an episome inside B cells --> a collection of DNA inside the B cells
• Cytotoxic T cells are activated to destroy the infected B cells