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NP Cert Exam > 3 Neurology > Flashcards

3 Neurology Flashcards

0
Q

Red flags for HAs

A 
SUdden onset HA 
First and worst 
Focal neuro sxs.   Mass AVM
Fever infxn
Change in personality or mental status

Majority of pts hv nl Hx

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1
Q

Number one neuro issue

A

Headaches
primary HA. Most. Tension traction pressure
Secondary HA underlying cause most pts >50 yrs

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2
Q

HA exam.

Don’t forget to check

A 
BP pulse
Fundoscopic exam. Papilledema  
From inc ICP. Brain tumor glaucoma 
Papate head neck shoulders 
Bruits (continuous noise ) AVM arteriovenous malformation a tangle of blood vessels in vein that bypass normal tissue and divert  blood from the arteries to the vein
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3
Q

Red flags for neuro exam

A

Age > 40 or 50
Neck stiffness
Neuro deficits
Papilledema- sxs represent swelling of optic disk almost always 2ndary to inc ICP

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4
Q

Increased ICP almost always gives

A

Papilledema bc sxs represent swelling of. Optic disk

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5
Q

Papilledema is

And almost always is

A

Swelling of optic disk r/t Inc ICP
Bilateral

Papilledema presents with swelling of optic disk

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6
Q

When to image for HA

A

“Red flag HAs”
Change in pattern
Neuro deficits

Papilledema
Get CT or MRI
Of brain and spine

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7
Q

95% of HA

A

Are migraines

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8
Q

Papilledema check. What does it look like

A

Blurred margins of optic disc indicate venous engorgement and Papilledema
Inc ICP

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9
Q

HA clues from location

Uni
Bilateral

A

Unilateral migraine
Bilateral tension
Always unilateral begins around eye or temple- cluster

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10
Q

HA characteristics.

How pain is described

A

Crescendo: migraine
Pressure tightness band like waxes and wains: tension
Pain peaks w in minutes excruciating explosive Cluster

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11
Q

HA duration
4-72 hrs
Varies
30-90 min usually up to 180 min

A

4-72 hrs migraine
Varies tension
30-90 min usually up to 180 min cluster

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12
Q

HAassociated sxs
Migraine
Tension
Cluster

A

Migraine. N V Aura ?
Tension. None
Cluster. Eyes become red tears rhinorhea ETOH can trigger

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13
Q

HA c nasal stuffiness.

A

Sinusitis

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14
Q

HA w jaw claudication (pain)with chewing , fever, visual loss, pain in temple

A

Temporal arthritis - giant cell arteritis

Inflammatory disease of arteries of head

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15
Q

HA w Visual field defect

A

Optic pathway lesion pituitary tumor

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16
Q

HA w blurred vision on bending of head

A

Intracranial lesion

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17
Q

HA w N/V

A

Tumor

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18
Q

Unilateral vision loss

A

Tumor

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19
Q

HA w sweating and tachycardia

A

Pheochromocytoma. Tumor in adrenal medulla

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20
Q

HA w Transient visual changes and intracranial noise - me!!

A

Pseudotumor cerebri (idiopathic intercranial hypertension

Also HA N/V pulsitile tinnitis (sounds in ears w same rhythm as pulse)
Without tx- inc swelling of optic disk and vision loss

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21
Q

Migraine HA. What changes in cerebral arteries occur?

A

Dilate! That is why tx is w triptan bc theyconstrict. So does caffeine

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22
Q

Diagnosis migraine without aura. Meet this criteria for Dx

A

Last 4-72 hrs

Has 2: unilateral, pulsing, mod to severe, aggravated by routine activity

Must have one: N/V, photophobia, phonophobia
5 or more attacks like above

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23
Q

Dx migraine w Aura

A

2 attacks w aura
Visual sensual or speech changes transient

Develops over 5-20 min. HA develops over 60 min

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24
Q

Migraine triggers

A

Stress
Menses
Skip meals
Weather sleep odors light ETOH smoking. Foods

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25
Q

Migraine pharm mngt

Mod severe:
If > 2 HA month use:

A

Mod severe 2x/m: use prophy! EXAM*****

  • Topiramate(Topamax). Divalproex (Depacote)- for migraines and seizure disorders
  • Beta blockers (Propanolol, timolol)
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26
Q

What is a med that is a good abortive for acute pain?

And good to keep in office bc drug seekers don’t want

A

Ketorolac (Toradol) IM.

Good for. Migraines, m/s, kidney stones

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27
Q

Exam. If >2 migraines a month use these meds

A

> 2x/m: use prophy! EXAM*****

  • Topiramate(Topamax). Divalproex (Depacote)- for migraines and seizure disorders
  • Beta blockers (Propanolol, timolol)

Limit use of Triptans bc cause rebound HAy

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28
Q

What disease causes cupping
And what is it

Exam***

A

Glaucoma

Cupping is when the optic nerve takes on a hollowed appearance with funds optic exam- bc of loss of ganglion cell axons

The donut whole of the optic nerve gets bigger bc of inc IOP

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29
Q

What is one of most common causes of facial pain?

A

Trigeminal neuralgia

Sudden severe unilateral facial pain

Cranial nerve 5 has three locations: top middle face and line going from top to jaw

Cotton wisp stroke on face causes pain

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30
Q

Facial pain sharp intense piercing - they see dentist a lot first bc think dental pain

Paroxysmal (comes and goes) pain

No neural deficit

A

trigeminal neuralgia

Common neuralgia in elderly

Exam***. Treatment: Carbamazepine (Tegretal)

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31
Q

What med is used with Trigeminal Neuralgia and also used for seizures and bipolar?

Pt education? EXAM

A

Carbamazepine( Tegretol).

Makes pt sleepy/drunk- don’t take till get home!

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32
Q

Acute peripheral facial nerve palsy

CN?

A

Bell’s palsy
CN VII
Caused by virus herpes

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33
Q

Bell’s palsy
Always r/o
Diagnosis and progression

A

R/o stroke

Onset over 1-2 days progressive
Max sxs in 3 wks
85% recovery in 3 weeks
Function returns 3-4 m

Edu: eye care
** psych support **. Give them hope! Tell them we will drive to full recovery. Hyperlacrimation.
Give Botox for facial spasm.

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34
Q

EXAM.
Bell’s palsy
New guideline

How much? When start?

A

“High dose” steroids will drive recovery from 30% to 10%!!!! Exa

Start w in 3 d of sx onset!!!!
60 mg Prednisone QD x3 d Whoa!
Then move to 50, 40, 30, 20,10

Also oral antiviral
Later Botox for facial spasm

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35
Q

Assessment for Bell’s palsy

A

CN VII

Close eyes
Elevate brow. Frown
Show teeth
Pucker lips
Tense soft tissue of neck

***. If can’t close eyes when blink. Ocular lubricant QH while awake
Sleep lacrolube on eye then paper tape eye at HS

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36
Q

These two meds used together are for:

-High dose oral steroids w in 3 d of sx onset!.
60mgx3 day then. 50. 40 30 20 10
Also
- Antiviral. Acyclovir….

A

Bell’s palsy

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37
Q

Sxs of Bell’s palsy

A

Unilateral
Drooping eye
Starts w a “twitch”

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38
Q

50 yo w Bell’s palsy Dx.

What will increase likelihood of complete recovery

A

high dose steroid stared w in 3 d of onset of sxs onset

39
Q

Symptom of vestibular fxn

Causes spinning and swaying
N and V. Postural instability
Single episode or recurrent

A

VERTIGO

40
Q

2 types of vertigo

Flip pt algorithm

A

Peripheral: Vestibular. I can manage in clinic. Prob BPV.
99% of vertigo this

Central: REFER. Brainstem or cerebellum.
***nystagmus lasts >1-2 min prolonged! -Exam!!!!!

Impaired gait and mobility

41
Q

peripheral vertigo sxs
Examples of

Central vertigo sxs

A

Peripheral vertigo: Severe vertigo. Severe N and V.

Recurrent vertigo Nystagmus lasts 1-2 min. Impaired gait and mobility. Single episode of vertigo lasting min to hrs

42
Q

Pt with hearing loss and vertigo probably has

A

Ménière’s disease. ENT refer

Ménière’s is auditory and vestibular disease
Vertigo. Hearing loss. Tinnitus.

Overproduction or impaired absorption of endolymph in inner ear
Low salt diet and diuretics

43
Q

Dix Hallpike maneuver provoked sxs for what?

A

Benign positional vertigo
BPV is brief and reproducible

Change in position provokes sxs
Dix Hallpike maneuver. Lay down and turn head to left or right - watch for vomit!

44
Q

Tx of vertigo

A

OTC antihistamines: meclazine. Dimenhydrate (Dramamine)

For severe vertigo:
Benzos. Alprazolam. Lorazepam(atavan)
Time

Get to ENT

45
Q

Vertigo

What to do

A

Refer most cases except BPV

46
Q

Rest vs action tremors

A

Rest. Occurs when tremulous body part is supported by gravity and not engaged in purposeful activity
Action. Occurs when the body part is not being used

47
Q

Chronic progressive neuro degenerative disorder characterized by rest tremor rigidity bradykinesia (slow movement) and gait disturbance

A

Parkinson’s disease

Diagnosis made by response to dopaminergic therapy. If movement smooth

48
Q

Cardinal features of Parkinson’s disease

A

Tremor at rest- pill-rolling (present in 70%)
Bradykinesia major cause of disability
Rigidity. Inc resistance to passive movement
Gait disturbance- FALLS primary concern

49
Q

What neurotransmitter is part of pathology in Parkinson’s?

Exam**

A

Dopamine!!!

50
Q

Pharm for Parkinson’s disease

A

Levadopa (Sinemet). Most effective usually first choice
With dopamine agonists to stim dopamine receptors
Anticholinergic meds

51
Q

Physiologic tremors

A

Not present under nl circumstances

Meds- amphetamines. SSRIs TCAs nicotine. ETOH withdrawal
Anxiety. Excitement fear

52
Q

What meds can help with physiological tremors

A

Propanolol

NP
Exams. Flights…..

53
Q

What is most common tremor?

A 
Essential tremor. 5% of population.  ET
Sometimes familial
More common w aging
Bilateral action tremor of hands forearms head voice chin lip - voice quivers in old ladies
Tremor on legs is unusual
54
Q

Clinical features of Essential tremor (ET)

Med used.
.

A

Apparent as arms are outstretched in front of body
More apparent at the end of a goal directed activity- hand shakes as glass gets closer to lips
No other neuro deficits

Propanolol mayhelp

55
Q

Always ask: does tremor go away when u drink ETOH?

A

If yes- usually Essential tremor Helps w diagnosis

56
Q

Cerebellar tumors

A

Refer now!!!
Etiology. Stroke, MS. Trauma
Can be postural. Kinetic or action

57
Q

What drug probably worsens sxs of Essential tremor ET?

A

Caffeine!!!

Makes better: Propanolol, alcohol, diltiazem (muscle relax)

58
Q

The most common inflammatory demyelinating disease of the CNS

Exam!!!

A

Multiple sclerosis. MS

59
Q

Multiple sclerosis sxs

A

Fatigue. Pain. balance problems. Visual loss. Unusual presentation

Sensory sxs. Numbness, tingling. Pins, tightness. Coldness. Swelling of limbs and trunk. Vision loss- field cut

2 clinically distinct episodes with at least partial resolution

60
Q

Exam. Most common disorder of neuromuscular transmission

Autoimmune disorder*

A

Myasthenia gravis. Remember videos of teens w this

61
Q

Most common upper and lower motor neuron disease.

Exam!

A

Exam!!
“A- my-o- trophic lateral sclerosis

Amyotrophic lateral sclerosis. ALS. Lou Gerhig’s disease - American baseball player. Harper Bates!

Destroys motor neurons the brain cells that control muscle movement
3-5 yrs usually…

Asymmetric limb weakness, hand weakness, foot drop

Increased risk in head injuries. Lou Gerrig was a football player before baseball

62
Q

Most common:

Inflammatory, demyelinating CNS disease

Disorder of neuromuscular, transmission

Upper and lower motor neuron disease

A

Inflammatory, demyelinating CNS disease: multiple sclerosis

Disorder of neuromuscular transmission: myasthenia gravis

Upper and lower motor neuron disease: amyotrophic lateral sclerosis. “A- my-o- trophic lateral sclerosis”

63
Q

Dementia

Impairment in—– Plus 1 or more cognitive domain —-

A

Dementia

Impairment in memory. Plus 1 or more cognitive domain —-

  • Apraxia: difficulty w motor planning to perform tasks or movement or speech when asked
  • Agnosia: Inability to process sensory info- can’t recognize objects, persons, sounds, shapes or smells, when the specific sense is not affected and there is no memory loss
  • Executive function. Aka cognitive control/ mngt of memory, reasoning, task flexibility, problem solving, planning and execution…
64
Q

Dementia mild cognitive impairment (MCI).

A

Memory impairment and difficulties.

65
Q

Mental status exam
MMSE. Good and quick
Exam determines:

A

No labs or imaging can detect. Must. Talk w Pt.

Exam determines:
Normal vs abnormal cognition
Dementia vs delirium
Primary psychiatric disease

66
Q

Cognitive testing that is most widely used and validated for sensitivity and specicifity

A

Mini mental status exam

Score less <24 suggests dementia or delirium
Assesses memory language and attention
Sample questions
1. Orientation to time. What is date
2. Registration. Repeat back words
3. naming- what is this
4. Reading. Read this and do what it says

67
Q

Physical exam for dementia

A

Look for something that is masquerading as dementia
Look for: Neuro deficits or tremors
Signs consistent with stroke
Gait difficulties

68
Q

Dementia look alikes

A

Medications:
Amelie’s brown bag test: bring in all meds u r taking- ones that can impair cognitive fxn- analgesics, anticholinergics( block neurotransmitter acetylcholine involved with parasympathetic nerve impulses that are responsible for involuntary smooth muscle responses). Bronchodilators!
Depression. Prior stroke. Tumor. Parkinson’s disease

1/5 of pts that present with sxs of Dementia have reversible! Go for that 20 %!!!!

69
Q

Labs for Dementia

AAN recs what imagining?

A

TSH and B12. *****

CBC. CMP electrolytes folate Consider RPR and HIV (low yield)

American academy of neuro (AAN) either for routine initial evaluation of dementia: No contrast head CT or MRI. Looking for anatomical abnormality like tumor or fluid
Findings can say “generalized and focal atrophy”- haha. Nl w aging
Screen for dementia bc it may be a co-
morbid

70
Q

Top 3 dementia in order of occurence

A

Alzheimer’s disease. 60-80%
Vascular dementia 10-20%
Parkinson’s dementia 5%

71
Q

Clinical dementia rating (CDR)

A

Assess severity of AD- memory. Orientation. Judgement. And problem solving community affairs home and hobbies
Used for driving etc…..

72
Q

Watch Triptan use as patients age bc can:

Exam*

A

Blood pressure can rise bc Triptans constrict blood vessels

So now switch to prophylactic meds like propranolol

Exam: pt w migraines for 20 yrs has newly developed HTN. Which med will now cause safety issue?
Amlodipine -(CCChBlocker for HTN a or CAD)
Sumatriptan
Simvastatin-(statin; dyslipidemia)
Amitriptyline- TCAS-depression, migraine HA, neuralgia

Answer: sumatriptan bc Constricts BV and BP could rise

73
Q

What is number one neurological ailment?

Temporal arteritis
Migraine HA
Bell’s palsy
Trigeminal neuralgia

A

Migraine!!!!

74
Q

A common comment from patients with Essential tremor is

A

Etoh improves sxs

75
Q

A 26 yo co asymmetric limb weakness. Which is not part of the diff?

Multiple sclerosis
Amyotrophic lateral sclerosis
Myasthenia gravis
Parkinson’s disease

A

Parkinson’s doesn’t cause weakness it causes a tremor

The rest could be weakness

76
Q

Which med is not used for migraine prophylaxis?

Amitriptyline
Propranolol
Sumatriptan
Feverfew

A

Sumatriptan is abortive! The rest are prophy

77
Q

What herb can be used for migraine prophylaxis?

A

Feverfew

78
Q

76 yo has sxs of dementia and poorly mngt HTN, and in no compliant w BP a meds. What kind of dementia might this suggest?

Lewy body dementia
Vascular dementia
Alzheimer’s dementia
Nothing in particular

A

Lewy body dementia - usually w Parkinson’s
Vascular dementia- yes!
Alzheimer’s dementia no
Nothing in particular

79
Q

A 35 yo has BPV. She has taken 4 doses of Meclazine in past 24hrs. Which statement is true?

  1. Meclazine is a once daily med
  2. She should be sx free now
  3. Her vertigo is probly better
  4. One or two more days of meclazine will be needed
A
  1. Meclazine is a once daily med- no, q4-6 h
  2. She should be sx free now- better but not
  3. Her vertigo is probly better- yes*
  4. One or two more days of meclazine will be needed
80
Q

CN mneumonic

A

O O O To Try And Feel very glossy vagina, Sperm heaven!

OlOpOcTrochTrig AbdFacVestGlossVagSpinacHypogloss

OLd OPen OCeans TROuble TRIbesmen ABout Fish VEnom Giving VArious ACute/SPlitting Headaches

81
Q

CN 1

A

Olfactory. Smell

82
Q

CN II

A

Optic. Snellen chart

20/80. Means at 20 feet, the patient can see what a normal person can see at 200 ft

83
Q

CN III

A

Oculomotor

Eye movements
Pupillary constriction
Accomodation

84
Q

CN IV

A

Trochlear

A good mnemonic to remember which muscles are innervated by what nerve is to paraphrase it as a molecular equation: LR6SO4R3

Lateral Rectus - Cranial Nerve VI
Superior Oblique - Cranial Nerve IV
the Rest of the muscles - Cranial Nerve III.

85
Q

LR6 SO4 R3

What CNs does it describe

A

Muscles of the eye and their cranial nerves

Abducens (abducts)Lateral rectus muscle VI 6

Superior oblique Trochlear (Trolley lifts up) IV 4

The rest of muscles III 3

86
Q

CN IV

A

Trochlear
Superior oblique muscle.
LR6 SO4 R3

87
Q

Mneumonic for CN eye muscles?

A

LR6 SO4 R3

Lateral rectus CN IV
Superior oblique VI
Rest of muscles III

88
Q

CN V

A

Cranial nerve V. Trigeminal.

Like trigeminal neuralgia- supplies sensation to the face- nasal buccal mucosa, and teeth. Mastication*

89
Q

CN VI

A

Abducens.

LR6 SO4 R3

90
Q

CN VII

A

Facial muscles and anterior 2/3 of tongue

CN IX 9 does post 1/3 tongue

91
Q

CN VII

A

Vestibulocochlear

Hearing, balance, awareness of position

92
Q

CN IX. 9

A

Glossopharyngeal
Sensation to pharynx
Post 1/3 of tongue
Tympanic membrane

93
Q

CN X

A

Vagus

Parasympatheticfibers to chest, abdomen, and motor fibers to pharynx, larynx, and
Sensory fibers to ear, meninges, viscera

94
Q

CN XI

A

Spinal accessory

Sternocleidomastoid and trapezius muscle

95
Q

CN XII

A

Hypoglossal

Muscles of tongue
Observe fasciculations when pt sticks out

NP Cert Exam (9 decks)

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