Chapter 48. Management of Neurological Disease Flashcards
Question 48-1:
A 56-year-old man has a cardiac arrest and suffers severe anoxic encephalopathy. There is some brainstem function, but he never regains consciousness and is dependent on ventilator and tube feedings. He does not have an advanced directive. The family wants the life supports removed.Which is the appropriate medical approach?
A. Consult the Ethics committee
B. Disconnect the life supports
C Continue the life supports
D. Perform EEG for determination of cerebral death
E. Have a court-appointed attorney make a substituted judgment
Answer 48-1: B.
In most states it is appropriate to discOlUlcCt
the life supports. It would not be unreasonable
to have an independent physician evaluate the
patient to advise regarding prognosis. so there
can be more security on the part of the
physician and family regarding prognosis.
Consulting the Ethics committee is usually not
necessary in these situations. There is no !X’int
in evaluation for brain death since the pattent
has some intact.brainstem function. A courtappointed attorney would have no role to play.
(p873)
Question 48-2:
Intractable pain from a peripheral nerve lesion would likely be managed best by which of the following approaches?
1. Tricyclic antidepressants
2. Anticonvulsants
3. SSRls
4. Controlled doses of sustained-release narcotics
Select: A = 1. 2. 3. B = 1. 3. C = 2.4. D = 4 only. E = All
Answer 48-2: A.
Most physicians do not prescribe narcotics for
non-malignant pain, although there are a few
vocal proponents of this regimen.
Anticonvulsants are a cornerstone for
treatment along with antidepressants. SSRIs
and TCAs alone or in combination are
conunonly used. (p871)
Question 48-3:
Increased exercise is helpful to augment strength for which of the following conditions?
1. Hereditary neuropathy
2. ALS
3. Parkinson’s disease
4. Myasthenia gravis
SelectA= 1,2,3. 8= 1,3. C=2,4. D=4only. E=AIl
Answer 48-3: A.
Exercise tends to exacerbate myasthenia
gravis, but can aid the other ::ooditions.
Although ALS and Parkinson’s disease are
progressive conditions, exercise can help. reestablish some motor function, resulting In
meaningful, though temporary, functional
improvements. (P872)
Question 48-4:
A 58-year-old man with advanced ALS has elected to forego intubation and other means of ventilatory support. When his ventilatory failure is imminent and he suffers from the anxiety of air hunger,which is the best treatment strategy?
A. Intubate and ventilate despite the patient’s wishes
B. Use supportive care only. No sedatives are given because they may hasten death
C. Use morphine or other sedative to lessen the anxiety and promote comfort even though it can hasten death
D. Consult the Ethics Committee
Answer 48-4: C.
This patient is terminal and lessening
suffering and anxiety with medications is the
right approach even though there is risk of it
hastening death. The treatment is not causing
death since that outcome has already been
detencined. Choosing the Ethics committee
consultation is not needed in this situation
since the patient already has advanced
directives not to intubate him. (p873)
Question 48-5:
A 25-year-old woman presents with her 4-year-old child, asking him to be tested for Huntington’s disease. Her father has clearly documented Huntington’s disease, but no one else in the family was known to be affected. Which clinical formulation would be the best?
A. Since no one else was affected, the woman’s father had a sporadic occurrence and will not pass it to his children. There is no need to test the woman or her child.
B. Testing the child would have implications for the mother as well. Genetic and psychologic counseling prior to a decision on testing is indicated
C It is the obligation of the physician to test regardless of the implications, so the examination should be perfomed at once
Answer 48-5: B.
Counseling is indicated prior to these tests
even if there is no child involved. Patients
often jump to the conclusion that a testshould
be performed without considering the
ramifications of the findings. Once the
genetic. psychologic. and medical issues have
been diScussed. me mother could cenainly be
tested.. Testing of children is even more
complicated and should be discouraged at this
age. The risk. of a child of a Huntington’s
patient without a known prior family history is
much less than the chance of one with a
known family history because new mutations
are rare in Huntington’s disease. (p874)
Question 48-6:
A 56-year-old man with progressive weakness bas corticospinal tract signs and widespread denervation on EMG. The diagnosis of ALS is made. Which is the most appropriate counseling regarding prognosis and outcome?
A. The patient can expect to expire within three years and there is no hope for stabilization or improvement.
B. Many patients with ALS stabilize and improve.
C. Most patients with ALS show gradual progression of the symptoms, but stabilization can occur.
D. ALS is a diagnosis only made with certainty at autopsy, so we cannot predict the prognosis of the patient.
Answer 48-6: C.
Counseling a patient with ALS or any oth!r
progressive disease must be a combination of
accuracy, compassion, and sensitivity. The
medical fact of lack of diagnostic certainty
also has to be considered, and in ALS there is
not only variability in progression of patients
but some uncertainty of diagnosis. While the
uncertainty does not have to be emphasized to
the patient, one should not close all doors to
hope, while still giving facts which will make
me patient consider life planning. (p874)
