DementiaCognitiveD/oComa_PretestStepUp

Question 1

What two components make up CONSCIOUSNESS? Which anatomical features correlate with each component?

Answer 1

AROUSAL + COGNITION

AROUSAL - Intact reticular activating system in MIDBRAIN
COGNITION - Intact cerebral cortex

Question 2

What are the diminished levels of consciousness?

Answer 2

DROWINESS
STUPOR
COMA

Question 3

What are two categorical etiologies of DECREASED CONSCIOUSNESS/COMA?

Answer 3

1) DIFFUSE INJURY TO BRAIN - Metabolic, systemic, toxic d/o

2) FOCAL INJURY TO BRAIN (intracranial lesion) - Hemorrhage, infarction, tumor

Question 4

Ddx of DELIRIUM (P DIMM WIT)

Answer 4

P - post-operative state (+narcotics)
D - Dehydration, malnutrition
I - Infection (sepsis, meningitis, UTI, pneumonia, encephalitis) 
M - Medications, Drug intoxications (Anti-cholinergics, TCA, hallucinogens, cocaine, corticosteroids) 
M - Metal poisoning (eg. Pb) 
W - Alcohol, BZ withdrawal 
I - Inflammation, fever
T - Trauma, burns

Question 5

Which medications can induce DELIRIUM?

Answer 5

Anti-cholinergics
TCA
Hallucinogens
Cocaine
Corticosteroids

Question 6

What is the Ddx of COMA/STUPOR (SMASHED)?

Answer 6

S - Structural brain pathology (stroke, subdural, epidural hematoma, tumor, hydrocephalus, herniation, abscess)
M - Meningitis, Mental illness (conversion disorder, catatonia - mimic coma)
A - Alcohol, Acidosis
S - Seizures (post-ictal), substrate deficiency (Thiamine)
H - Hypotension/cerebral hypoperfusion, Hypo/hyperthermia, Hypercapnia (CO2), Hypoxia, Hyponatremia, Hypo/hyperglycemia, Ca/Mg/P disturbances
E - Endocrine (Addison, thyrotoxicosis, hypothyroid), Encephalitis, Encephalopathy (HTN, hepatic, uremic)
D - Drugs (Opiates, barbiturates, BZ, other sedatives), CO, CN, Methanol
P- Psychotic (malingering/ conversion d/o are difficult to differentiate from true coma)

Question 7

Are structural brain lesions that cause COMA usually UNILATERAL or BILATERAL?

Answer 7

Usually BILATERAL, unless it is UNILATERAL with enough mass effect to compress the brainstem or opposite cerebral hemisphere

Question 8

What are the 3 components of the GLASGOW COMA SCALE?

Answer 8

E - Eye movement
M - Motor response
V - Verbal response

Question 9

Brain death can NOT be established in the presence of ____ (Hint: VS)

Answer 9

HYPOTHERMIA (Temp<32, 89.6F)

Question 10

How do you distinguish between PERSISTENT VEGETATIVE STATE and BRAIN DEATH?

Answer 10

Main one = BRAINSTEM REFLEXES (Blink to threat, corneal reflex, VOR, gag reflex)

PVS = +Brainstem reflexes (-C, +B, +H, +M)
BD = - Brainstem reflexes (+H, -C, -H, -M)

Question 11

In determining the etiology of COMA, BILATERALLY fixed, dilated pupils is most likely due to __?

Answer 11

SEVERE ANOXIA

Question 12

In determining the etiology of COMA, UNILATERALLY fixed, dilated pupils is most likely due to __?

Answer 12

CNIII Compression by UNCAL HERNIATION, or PComm Aneurysm

Question 13

In determining the etiology of COMA, PINPOINT PUPILS is most likely due to __ and __?

Answer 13

NARCOTICS
ICH of the PONS
(ICH of thalamus - slowly reactive, ICH of putamen - dilated)

Question 14

Which dementia has the hallmark of SMALL VESSEL CEREBRAL ISCHEMIA?

T2 WEIGHTED DENSITY SCAN: Multiple areas of increased density in PERIVENTRICULAR AREAS

Answer 14

MULTI-INFARCT DEMENTIA