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Albacete: schedule and where to watch the SmartBank League match

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The ball rolls again in a new SmartBank League game. He Fuenlabrada and the Albacete face next Sunday, October 20 in the football match corresponding to day 12 of the SmartBank League. The match is played at the stadium Fernando Torres at 12:00 and it can be seen live through M. LaLiga.

The web of La Vanguardia will also offer all the news of the crash live, as well as the minute by…

Numancia – Zaragoza live: LaLiga Smartbank live

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Real Zaragoza, after four days without winning (three draws and one defeat), Victor Fernandez's team goes to Soria ready to start a new escalation of victories and give the first one to Raphael Dwamena, who, suffering from a serious pathology cardiac and, waiting for new medical opinions, seems destined to the withdrawal of football, at least temporarily.

The Aragonese club is already…

Pancreatitis and Pancreatic Cancer

I can’t even stress to you how frequently PA students are tested over pancreatitis (acute and chronic) and pancreatic cancer. It seems to be one of those vague presentations that test writers take advantage of by placing in distractors (answers that seem right, but are in fact incorrect). This is meant to be a short, but hopefully helpful review of each of them, so that you are better prepared to tackle questions on these topics regardless of if they’re your in house exams during didactic, PAEA end-of-rotation exams, the PACKRAT, the PANCE, or the PANRE. I hope this helps you regardless of which avenue you find it useful. Good luck and make sure to check out TrueLearn’s free sample questions below! I’ll say, I loved their gastroenterology section the most. The vignettes were on point and difficulty wise - they were spot on with the EORs and PANCE-style questions.

Acute and Chronic Pancreatitis

Acute Pancreatitis

Inflammation of pancreas from prematurely activated enzymes → pancreatic autodigestion

Causes: ETOH (40%), gallstones (40%), post-ERCP, viral infection, drugs, scorpion bites, pancreatic cancer, hypertriglyceridemia, hypercalcemia, uremia

Blunt trauma (MCC in children)

Mild (most common)

- Abdominal pain, epigastric, radiates to back (50%), steady, dull, and severe

-Worse when supine and after meals

-Nausea, vomiting, anorexia

Signs

- Low grade fever, tachycardia, hypotension, leukocytosis

-Epigastric tenderness, abdominal distention

-Decreased/absent bowel sounds

-Hemorrhagic pancreatitis: Grey Turner’s sign (flank), Cullen’s Sign (periumbilical), Fox’s sign (inguinal ligament)

1. Serum amylase (MC) - nonspecific, absence does not r/o, 5xULN, normal 48-72 hours after

2. Serum lipase - more specific (3xULN)

3. LFTs - possible gallstone pancreatitis

4. Hyperglycemia, hypoxemia, leukocytosis

5. Ranson’s criteria: glucose, calcium, hematocrit, BUN, ABG, LDH, AST, WBC

6. KUB - r/o perforation

7. Abdominal U/S - identifies cause

8. CT scan (confirmatory) - most accurate

9. ERCP - severe with obstruction

1. Mild - Bowel rest (NPO), IVF, replete electrolytes, pain control (Fentanyl, Meperidine)

2. Severe - high mortality; ICU admit

-Enteral nutrition in first 72 h through NJ tube

Recurrence high in ETOH related

Complications:

- Pancreatic necrosis

- Pancreatic pseudocyst

Chronic Pancreatitis

Persistent, continued inflammation of pancreas → fibrosis and alteration of ducts = irreversible

Causes: chronic ETOH-ism

Other: hereditary, tropical, idiopathic

Severe epigastric pain, recurrent or persistent

-Nausea and vomiting

--Aggravated by drinking or eating

-Radiates to back

-Weight loss due to malabsorption, ETOH, diabetes

-Steatorrhea due to malabsorption

1. CT scan (first) - calcifications, normal does not r/o

2. KUB - pancreatic calcifications (95% specific)

3. ERCP (gold standard): “chain of lakes”

4. Serum amylase and lipase not elevated, other labs not helpful

5. Stool elastase - most sensitive and specific for pancreatic insufficiency (steatorrhea secondary to malabsorption)

1. Pain meds, NPO, pancreatic enzymes and H2 blockers, insulin, ETOH abstinence

2. Frequent, small volume, low fat meals

3. Surgery - pancreatico-

jejunostomy or pancreatic resection (Whipple’s)

Complications

-Narcotic addiction (most common)

-DM - loss of islets of Langerhans

-Malabsorption: late manifestation

-Pseudocyst

-CBD obstruction

-B12 malabsorption

-Effusions

-Pancreatic carcinoma

Pancreatic enzymes - inhibit CCK release, decreasing pancreatic secretions after meals

H2 blockers - inhibit gastric acid secretion, preventing degradation of enzyme supplements by gastric acid

Pancreatic Pseudocyst

Pancreatic Pseudocyst

Patients with chronic pancreatitis from alcohol usage or gallstones are at risk

10% occur after acute pancreatitis

Collection of fluid surrounded by granulation tissue

If it communicates with the pancreatic ductal system, it can contain digestive enzymes; does not contain epithelial lining (not cystic lesion of the pancreas)

1. Persistent abdominal pain, anorexia, or abdominal mass after pancreatitis

2. Jaundice or sepsis from infection (rare)

Physical exam

1. Tender abdomen

2. Palpable abdominal mass

3. Peritoneal signs suggesting rupture

4. Fever

5. Scleral icterus

6. Pleural effusion (common)

1. CT scan (standard)

2. ERCP - not for diagnosis, but useful for drainage

Labs

1. Serum amylase and lipase: elevated, limited use

2. Serum bilirubin and LFTs: elevated, limited use

3. Cyst fluid analysis: CEA, CEA-125, fluid viscosity, amylase (all low)

1. Supportive care only - MOST

2. Drainage for - complications, symptoms, possible malignancy

a. Percutaneous catheter drainage (preferred)

B. ERCP

C. Surgical Drainage (standard)

10% become infected, but can also rupture causing peritonitis or death

Poor prognostic factors: size of cyst and duration of presence

Outpatient monitoring: if stents placed, monitor with serial CT scans to observe resolution

Pancreatic Cancer

Pancreatic

Cancer

Most common in elderly patients (>60), African Americans

Anatomic location: pancreatic head (75%), body (20%), tail (5-10%)

RF: smoking, high fat diets, age >45, male gender, chronic pancreatitis, diabetes, heavy alcohol use, exposure to chemicals, first degree relative

Most adenocarcinomas (50%) involving head of pancreas

-Abdominal pain: vague and dull ache, epigastric, may radiate to back

-Painless Jaundice: most common with carcinoma of the head

-Weight loss; anorexia

-Recent onset glucose intolerance, but diabetes is mild

-Depression, weakness, fatigue

--Trousseau's sign: Migratory thrombophlebitis (10%)

-Courvoisier's sign: painless palpable gall in 30%

1. CT scan (preferred): pancreatic mass, dilated pancreatic and hepatic metastases, vascular involvement  

2. ERCP - most sensitive (confirms diagnosis); obtain sample for biopsy

3. MRCP - noninvasive, visualize hepatic and biliary symptoms, no tissue sampling

Tumor markers

1. CA 19-9 (more sens/spec)

2. CEA

1. Surgical resection with pancreatico-

duodenectomy  (Whipple’s procedure)

2. Chemotherapy: 5-FU and Gemcitabine

3. If unresectable - ERCP or PTC with stent placement

4. Most treatment is palliative care because of metastases

Prognosis: 5-year survival rate is 10%

1. A 45-year-old man is evaluated for a one-year history of severe chronic abdominal pain. The pain is located in the epigastric and left upper quadrant regions. Certain foods appear to precipitate the pain; however, it is unaffected by antacids. Associated symptoms include repeated bouts of loose steatorrhea and a 10 pound weight loss over the last 6 months. Three years ago he was hospitalized for acute abdominal pain. He smokes one pack of cigarettes per day and consumes 6-10 beers daily. His family history is significant for diabetes in his mother. On physical examination, he appears well. He does not have any scleral icterus.

Which of the following is most likely to confirm the diagnosis?

CA 19-9

D-xylose absorption test

HIDA scan

Serum amylase and lipase

Stool elastase

Explanation:

An alcoholic patient presenting with chronic abdominal pain and diarrhea is a classic case description of chronic pancreatitis. Chronic inflammation of the pancreas, most commonly secondary to alcohol or gallstones, is characterized by abdominal pain and symptoms of pancreatic insufficiency. Pancreatic insufficiency typically manifests first as exocrine dysfunction (i.e., fat malabsorption) with gradual progression to endocrine dysfunction (i.e., diabetes) if the insult continues. The diagnosis of chronic pancreatitis can be somewhat difficult to make. Stool elastase can be beneficial in diagnosing malabsorption secondary to pancreatic exocrine insufficiency. This test is the most sensitive and specific test for pancreatic insufficiency.

Answer A: CA 19-9 is a biomarker for pancreatic cancer. The most common presenting symptom of pancreatic cancer is painless jaundice. In contrast, this patient presented with severe chronic pain. While weight loss is associated with malignancy, the history of diarrhea does not fit a diagnosis of cancer as well as one of chronic pancreatitis.

Answer B: Although a D-xylose absorption test would demonstrate that the patient above is suffering from malabsorption, unlike stool elastase, it is not specific to the pancreas.

Answer C: HIDA scans are useful for evaluating the function of the gallbladder.

Answer D: Serum amylase and lipase may be modestly elevated but are more commonly normal due to the presence of significant fibrosis and only patchy inflammation in chronic pancreatitis.

Upper GI endoscopy would not be helpful here. This would be more useful in the diagnosis of upper GI diseases, such as peptic ulcer disease.

Bottom Line: Stool elastase can be used to diagnose chronic pancreatitis.

For more information, see http://emedicine.medscape.com/article/181554-overview

2. A 40-year-old man presents for a routine check-up. Physical exam is within normal limits. Labs show a triglyceride level of 1500-mg/dL, total cholesterol of 140-mg/dL and LDL of 100-mg/dL. His blood pressure is 140/90 and he smokes one-half-a-pack per day. He is at risk for pancreatitis due to his:

Hypertension

Smoking

LDL cholesterol level

Triglyceride level

Total cholesterol level

Explanation:

This patient has elevated triglycerides while the rest of the lipid profile is within normal limits. A high triglyceride level is a risk factor for pancreatitis. His blood pressure is on the border while his triglycerides are very elevated. Below is the typical appearance of acute pancreatitis on a CT scan. Answers A, C, & E: Hypertension and high cholesterol are risk factors for stroke. His LDL is within normal limits, thus his risk for coronary artery disease is low.

Answers A & C & E: Hypertension and high cholesterol are risk factors for stroke.  His LDL is within normal limits, thus his risk for coronary artery disease is low.

Answer B: This patient has only one risk factor for coronary artery disease, namely smoking.

Bottom Line: A high triglyceride level is a risk factor for pancreatitis. While this patient has high blood pressure, blood pressure should be measured on three separate occasions before diagnosing hypertension.

For more information, see: http://emedicine.medscape.com/article/181364-overview

3. A 30-year-old man presents with severe abdominal pain, nausea and vomiting for the last few hours. He was eating pizza and drinking beers with a few friends when the pain began. The pain radiates from his epigastrium directly to his back and is constant. He has never had pain like this before, and he states that he has no known medical problems. He drinks a few beers and smokes a few cigarettes with his friends during the weekend but denies using either consistently. His family history is significant for a father that died of a myocardial infarction at 45, and a grandfather with coronary artery disease. On examination, his temperature is 38°C (100.4°F), pulse is 115 beats/minute, respirations are 20 breaths/minute, and blood pressure is 105/65 mm Hg. There is severe pain on epigastric palpation and there are several xanthomas under his eyes. His laboratory values are shown below.

Leukocyte count 18,000 cells/mm3

Lipase 175 U/L

AST 70 U/L

ALT 55 U/L

Alkaline phosphatase 80 U/L   

Which of the following is the most likely cause of his symptoms?

Alcohol

Cigarette smoking

Factitious disorder

Gallstones

Hypertriglyceridemia

Explanation:

Although the most common causes of acute pancreatitis are gallstones and alcohol, this patient has a more rare cause - hypertriglyceridemia. His family history of a grandfather with coronary artery disease and a father with a early death from a myocardial infarction suggest he may have a form of familial hypertriglyceridemia. His xanthomas also suggest hypertriglyceridemia. This should be treated immediately to decrease his morbidity and help improve his pancreatitis. In the meantime, this patient requires abdominal imaging to view the pancreas and should receive fluids and bowel rest.

Answer A: Alcohol is a common cause of pancreatitis, but it is more often a result of chronic alcoholism not the social drinking this patient describes.

Answer B: Recent studies have documented a link between cigarette smoking and acute pancreatitis, but it occurs as a result of long-term, consistent usage, not the social smoking described by this patient.

Answer C: In factitious disorder, the patient fakes or causes a condition for primary gain of being taken care of in the sick role. This patient has pancreatitis, which he is not causing on his own.

Answer D: Gallstones are an extremely common cause of pancreatitis. Although this patient should certainly receive a right upper quadrant ultrasound to search for any stones, his chronic hypertriglyceridemia is a more likely cause. Gallstones usually present with right upper quadrant pain preceding the episode of pancreatitis, and the risk factors for gallstones are usually obesity, female sex, fertility, and age over 40.

Bottom Line: Hypertriglyceridemia is a known cause of pancreatitis.

Seizures, Headaches, and Migraines

Updated: 04/18/2016

Seizures, headaches and migraines are some of the most commonly occurring questions on the PACKRAT, EORE, PANCE, and PANRE. Since they also occur commonly in practice, you’ll definitely want to cover these topics thoroughly. Knowing the subtleties between each and the questions to ask is important not only for your understanding, but so you can treat the patient accordingly with the most appropriate therapy.

While Neurology only makes up 6% of the PANCE, knowing topics like this well can mean the difference between passing and not passing. As I have stated before, one of the best ways to prepare for your exams is through quality question banks and study guides. TrueLearn has introduced an incredible opportunity to work with the PA-student and PA community to help us excel in our didactic education and clinicals, and on our boards. See below for our second post discussing Seizure Disorders and Headaches and Migraines.

Remember from last month that TrueLearn’s SmartBanks include specialized medical content crafted to mirror End of Rotation Exams (EORs), the PACKRAT, the PANCE and the PANRE. This means that the best test writers have come together to write questions that not only get your juices flowing, but challenge you to think critically - the most important characteristic of great PAs.

Visit TrueLearn.com/Physician-Assistant/ today to learn more about their physician assistant products.  

Disclosure: I am not an employee of TrueLearn.

Seizure Disorders - sudden abnormal discharge of electrical activity

Epilepsy - syndrome of recurrent, idiopathic seizures

In seizures, duration of unconsciousness tends to be longer than in syncope (momentary)

In syncope, bladder control is retained, but lost in seizures

Causes: four Ms and four Is

Metabolic and electrolyte disturbances - hyponatremia, water intoxication, hypoglycemia and hyperglycemia, hypocalcemia, uremia, thyroid storm, hyperthermia

Mass lesions - brain mets, primary brain tumors, hemorrhage

Missing drugs

Non-compliance with anticonvulsants (most common reason)

Acute withdrawal from alcohol, benzos, barbituates

Miscellaneous

Pseudoseizures - psychiatric in origin

Eclampsia

Hypertensive encephalopathy

Intoxication - cocaine, lithium

Infection - septic shock, bacterial or viral meningitis, brain abscess

Ischemia - stroke, TIA (common in elderly)

Increased ICP due to trauma

Diagnosis

If known epileptic → check anticonvulsant levels

If first seizure

CBC, CMP (LFTs), blood glucose, renal function tests, serum calcium, urinalysis

EEG: most helpful diagnostic test, abnormal pattern is not diagnostic alone

CT scan of head: r/o structural lesions

MRI of brain with and without gadolinium: more sensitive than CT for structural changes

LP/blood cultures if febrile

Pregnancy test - before initiating anticonvulsants!!!

Treatment

ABCs first, secure airway and roll patient to side

Known epileptics

Check for non-compliance of anticonvulsant, check levels

If persistent with monotherapy, increase dose of first anticonvulsant until signs of toxicity appear → add second drug if seizures uncontrolled

If controlled → continue regimen x 2 years, then taper

First seizure

EEG with neurology consult

Anticonvulsant therapy

If normal EEG, recurrence low (15%) compared to abnormal EEG (41%)

Do not treat patients with single seizure - start antiepileptics if EEG abnormal, MRI abnormal or status epilepticus

Partial Seizures (70%), begins in one part of brain (temporal) and produces symptoms referable to region of cortex involved

May evolve into generalized seizures (called Secondary Generalized)

Simple

Consciousness intact

Seizure - localized, but may evolve

May involve transient unilateral clonic-tonic movement

EKG: localized disturbances

1. Phenytoin and carbamazepine

2. Alternatives - phenobarbital, depakote, primidone

Complex

Consciousness impaired

Postictal confusion

Automatisms (last 1-3 mins): purposeless, involuntary, repetitive movements (lip smacking, chewing)

Olfactory and gustatory hallucinations

1. Phenytoin and carbamazepine

2. Alternatives - phenobarbital, depakote, primidone

Generalized Seizure - loss of consciousness; disruption of electrical activity in entire brain

Tonic Clonic (Grand Mal)

Bilaterally symmetric & without focal onset

-Begins with sudden LOC, “falls to ground”

-Tonic phase: rigid, trunk and limb extension occurs, may become apneic

-Clonic phase: muscular jerking of limbs and body for 30 seconds

-Patient becomes flaccid & comatose before regaining consciousness

-Postictal confusion & drowsiness, lasts hours (mean: 10-30 mins)

Other features: tongue biting, vomiting, apnea, incontinence (feces, urine)

EKG: generalized high amplitude, rapid spiking

1. Phenytoin and carbamazepine

2. Alternatives - phenobarbital, depakote, primidone

Absence (Petit Mal)

-School aged children, resolves as you age

-Disengage from current activity and “stare into space” - then returns to activity

-Patient looks “absent minded” during episodes which are confused with “daydreaming”

-Brief (lasts few seconds), but quite frequent (100 times/day)

-Impairment of consciousness but no loss of postural tone or continence, and no postictal confusion

-Minor clonic activity (eye blinks, head nodding, 45%)

EKG: spike and wave activity

1. Ethosuximide

2. Depakote (valproic acid)

Secondary Generalized

Partial seizures that evolve into generalized seizures

Status Epilepticus - prolonged, sustained unconsciousness with persistent convulsive activity in seizing patient lasting longer than 30 minutes OR 2+ sequential seizures without full recovery of consciousness between seizures.

Medical emergency - mortality is 20%

May be caused by poor compliance with meds, alcohol withdrawal, intracranial infection, neoplasm, metabolic disorder, drug overdose

Management: establishing an airway, giving IV diazepam, IV phenytoin, and 50 mg dextrose

Resistant cases: IV phenobarbital

Migraines, Tension Headaches, Cluster Headaches

Aggravators of migraines: menstruation, stress, anxiety, lack of sleep, drugs/foods (chocolate, cheese, alcohol, smoking, OCPs), weather changes

Visual aura in migraine: bilateral homonymous scotoma; bright, flashing, crescent shaped images with jagged edges appear on a page, obscuring the underlying print, lasts 10-20 minutes

Migraines with aura (15%)

“classic migraine”

Autosomal dominant with incomplete penetrance

Serotonin depletion

Women > Men

(+) family history

1. Visual aura: flashing lights, scotomata, visual distortions

1. Acute migraines

--NSAIDs, Tylenol, DHE or a Triptan

--DHE (5-HT1) agonist: highly effective

--Sumatriptan (5-HT1 agonist): rapid and effective, 1-2 times/week

2. Prophylaxis

--Avoid precipitants

--TCAs and Propranolol (most effective)

--Verapamil, Depakote, Methysergide

Migraines without aura (85%) “common migraine”

1. Prodromal phase (30%)

-Excitation or inhibition of CNS: elation, excitability, increased appetite or craving for foods, depression, irritability, sleepiness, fatigue

2. Severe, throbbing, unilateral headache

-Lasts 4-72 hours

-Generalized over entire head, lasting for days

-Aggravated by coughing, physical activity, or bending down

-”throbbing, dull, achy”

3. Nausea, vomiting (90%), photophobia, increased sense of smell

Menstrual migraines

Occurs 2 days before menstruation and last day of menses, estrogen withdrawal

--NSAIDs

Estrogen supplementation

Status migrainosus

Lasts >72 hours and does not resolve spontaneously

Tension Headaches

Unknown cause

Worsens throughout the day

Precipitants: anxiety, depression, stress

1. Pain - steady, aching, “vise-like” and encircles entire head (tight band-like), generalized but most intense around neck or back of head

2. Tightness in posterior neck muscles

Find causal factors, evaluate for depression or anxiety

Reduce stress

Mild/Mod: NSAIDs, Tylenol, ASA

Severe: migraine meds appropriate

Cluster Headaches

Rare

Middle-aged men

1. Episodic (90%) - last 2-3 months, with remissions of months to years

2. Chronic cluster headaches (10%) - last 1-2 years, headaches do not remit

1. Excruciating periorbital pain (“behind the eye”) - almost always unilateral

2. Deep, burning, searing, or stabbing pain

3. Ipsilateral lacrimation, facial flushing, nasal stuffiness/discharge

4. Begins few hours after patient goes to bed, lasts 30-90 minutes, awakens from sleep (daytime cluster headaches occur)

5. Occur nightly 2-3 months, then disappear

6. Worse with alcohol and sleep

1. Acute attacks

a. Sumatriptan (Imitrex)

b. O2 inhalation

2. Prophylaxis

Most responsive to Verapamil

Ergotamine, methysergide, lithium, steroids

Resolution of headaches within 1 week

TrueLearn’s Neurology Sample Questions

Question 1: A 45-year-old male is brought to the emergency department by ambulance after having a witnessed seizure. He is currently alert, but not oriented to himself or his surroundings. After his initial assessment, he begins to seize violently. He is given 5mg of midazolam intravenously yet continues to seize. An additional 10 mg of midazolam is administered intravenously, yet the patient continues to shake violently. Vitals reveal a blood pressure of 190/100 mmHg, a heart rate of 130/min, a respiratory rate of 44/min, and a room air oxygen saturation of 88%. The most appropriate course of action is

call for a stat neurology consultation

continue using benzodiazepines intravenously until his seizure stops

prepare to intubate the patient using propofol as the induction agent

provide bag-valve-mask ventilation until his seizure stops

roll him on his side to prevent aspiration

Explanation:

This is an example of status epilepticus (SE). Current definition of SE is more than 30 minutes of continuous seizure activity, or two or more sequential seizures without full recovery of consciousness between seizures. This patient had two sequential seizures without clearing from his post-ictal state, followed by continued seizure activity following high dose benzodiazepines. Benzodiazepines are the first line treatment for seizures. When this fails, one must resort to the ABC’s of patient care. This patient has no ability to control his airway if he continues to seize. Immediate recognition of this is critical. Intubation is indicated for airway protection. Propofol is the induction agent of choice because it is a powerful anti-epileptic drug (AED) as well as a commonly used induction agent for rapid-sequence-intubation.

Answer A: Call for a stat neurology consultation is incorrect. The patient needs immediate stabilization of his airway. Remember the ABCs. Airway, breathing, and circulation come before all else. Once the patient is stabilized (via intubation and sedation), you have a high priority to call neurology for continuation of care.

Answer B: Benzodiazepines are the first line treatment for seizures, and are effective in the majority of cases. This patient has failed high dose treatment with a benzodiazepine, and continues to seize. Therefore a different medication should be used. Frequently used alternatives are phenobarbital and propofol, which are both powerful medications used to suppress seizure activity. When using either of these medications, the respiratory drive will be decreased and therefore intubation is usually required.

Answer D: Bag-valve-mask (BVM) ventilation will not help this patient. In fact, forcing breaths into this patient will likely only induce aspiration and possibly produce aspiration pneumonitis. His oxygen saturation should be maintained by simple nasal cannula or non-rebreather mask that will not force air into the trachea or esophagus.

Answer E: This patient requires immediate protection of his airway. Rolling him onto his side may transiently help prevent aspiration, but has done nothing to treat the underlying pathology. A patient in SE can inhale saliva, blood and gastric contents regardless of the way they are positioned, thus making this answer incorrect.

Bottom Line: Status epilepticus is defined as more than 30 minutes of continuous seizure activity or two or more sequential seizures without full recovery of consciousness between seizures. Management includes high dose benzodiazepines and management of the ABCs.

TrueLearn Insight : Remember the ABCs in all patients who are critically ill. You will have distractions and other management possibilities. When in doubt, be aggressive about protecting the patient by ensuring they have adequate airway protection/patency, spontaneous breathing, and adequate circulation. Do not move on until these are stable.

For more information, see:

Arif H, Hirsch L. Treatment of Status Epilepticus. Semin Neurol 2008;28:342–354. http://criticalcaremedicine.pbworks.com/f/Treatment+of+Status+Epilepticus.pdf

Ayala C, Spellberg B. Boards and Wards. 4th Ed. Philadelphia, PA; Lippincott Williams & Wilkins; 2010: 378-379. "Status epilepticus" on Medscape. http://emedicine.medscape.com/article/1164462-overview.

Question 2: A 46-year-old man with a history of hypertension visits your office and complains of frequent headaches over the past year. The pain generally begins behind the right eye and expands throughout his skull as time progresses. The pain is constant, severe, and persists for hours or days. The headaches are not preceded by visual perceptions of flashing lights or zigzag lines. He does not experience muscle weakness, difficulty speaking, or dizziness. Occasionally the patient experiences nausea during the headaches, but he does not vomit. Caffeine sometimes helps diminish the pain. He is most comfortable lying in a dark, quiet room until the pain subsides. On physical examination, his heart rate is 90 beats/minute, respiration rate is 12 breaths/minute, and blood pressure is 182/96 mm Hg. His neurological exam is benign and non-focal. Other than a chronic cough that has improved since he stopped taking his blood pressure medication, the patient has no other medical problems or symptoms. Which of the following would be the best prophylactic treatment option?

Captopril

Losartan

Propranolol

Sumatriptan

Venlafaxine

Explanation:

The patient’s headaches are consistent with common migraine, also known as migraine without aura. The absence of preceding visual disturbances (zigzag lines, flashing lights) or motor weakness excludes the diagnosis of migraine with aura. The absence of dizziness or difficulty speaking generally excludes basilar migraine. Beta-blockers such as propranolol are often used for migraine prophylaxis. Propranolol is also a good choice considering this patient has a history of hypertension and demonstrates elevated blood pressure on exam. He has been non-compliant with his previous antihypertensive, likely an ACE inhibitor (angiotensin converting enzyme inhibitor), which elevates bradykinin levels and can lead to chronic cough.

Answer A: Captopril (ACE inhibitor) is likely similar to his previous hypertension medication and would cause his cough to return; additionally, it is not effective for migraine.

Answer B: Losartan (angiotensin receptor blocker) is effective against hypertension but would not be useful for migraine.

Answer D: Sumatriptan is very effective for migraine headaches, but as this patient also suffers from hypertension, propranolol is a better choice. It also would be a good abortive therapy but is not effective as prophylaxis.

Answer E: Venlafaxine has gained recognition for its efficacy with migraines, but it generally is not used as a first-line therapy unless the patient also suffers from a depressive disorder.

Bottom Line: In patients with migraine and uncontrolled hypertension, either a beta-blocker (propranolol) or calcium channel blocker (verapamil) would be the most logical medication to prescribe as each demonstrates efficacy in both conditions.

TrueLearn Insight : 1) Imaging is generally unnecessary in patients with headache unless there is focal neurological change, suspicion of acute intracranial process, or suspicion of basilar migraine. 2) Although caffeine can help alleviate symptoms for some migraine sufferers, its use can also contribute to migraine headaches and hypertension. For more information, see www.uptodate.com "Preventive treatment of migraine in adults"

Question 3: A 45-year-old man is pacing in the emergency department waiting room and complaining of headache. He says that this is the fifth headache he has had this week, and he rushed to be seen because the last four went away before he could get to the doctor. The pain is 8/10 in severity and it feels “like being stabbed in the eye,” always on the right. He says he had pain like this several years ago when he had a series of severe headaches over the period of about a month, but they had gone away. He has tried taking aspirin, ibuprofen, and acetaminophen but does not feel they have helped. His past history is significant for an inguinal hernia that was repaired seven years ago. His mother suffers from acute angle-closure glaucoma and migraine and his father died of a myocardial infarction at the age of 47. He does not smoke and drinks alcohol occasionally. On examination his right eye is injected and there is right-sided ptosis. Fundoscopic examination is normal. Which of the following is the next best step in management?

Head CT

High-flow oxygen

Intranasal sumatriptan

Lithium carbonate

Lumbar puncture

Explanation:

The patient’s history and exam are classic for cluster headache (severe unilateral stabbing pain, with injection and lacrimation of the ipsilateral eye, often with ptosis and miosis), which is treated acutely with high-flow oxygen.

Answers A and E: He does not need a head CT or lumbar puncture as the diagnosis is clear and there is no evidence of acute intracranial process.

Answer C: Intranasal or injected sumatriptan is appropriate after initiating oxygen therapy.

Answer D: Lithium carbonate has been suggested as a preventive medication for cluster headache but is not used to abort an acute attack.