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FNP III - Test 1 > Module 5 > Flashcards

Module 5 Flashcards

1
Q

Transient interruption of arterial blood flow to an area of the brain supplied by a particular artery with an episode of neuro dysfunction r/t focal brain, spinal cord, or retinal ischemia WITHOUT acute infarction or tissue injury; considered medical emergency

A

TIA

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2
Q

Risk of severe stroke highest within_____hours of TIA

A

48 Hours

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3
Q

Typically associated with focal neuro deficit and/or speech disturbance
Sudden onset of sx; typically last less than an hour (often just minutes)

A

TIA

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4
Q

Diagnostics for TIA

A

CBC, PT/INR, CMP, FBS, lipids, urine drug screen, ESR
Neuroimaging within 24 hours!!
* MRI preferred, CTA if MRI cannot be performed

Carotid duplex scan
ECG/echo/TEE (if afib expected)
Holter monitor for a fib

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5
Q

Predicts subsequent risk of TIA or stroke

A

ABCD2 Risk Score

Age: >60 (1 pt)
BP greater than or equal to 140/90 on 1st eval (1 pt)
Clinical sx: focal weakness with TIA (2 pt); speech impairment without weakness (1 pt)
Duration >60 min (2 pt); 10-59 min (1 pt)
DM (1 pt)

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6
Q

Management after TIA

A

Primary aim: decrease risk of subsequent stroke or TIA (PREVENTION )

Dual antiplt with aspirin and clopidogrel for 3 wks - 1 month followed by a single antiplt agent best antiplt plan for TIA pts

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7
Q

A LASTING interruption of blood circulation to the brain

A

CVA Stroke

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8
Q 
(13% all strokes)
More lethal, younger adults
HTN, trauma, drug use
Ruptured aneurysm, vascular malformation
HA prominent sx*
A

Hemorrhagic stroke

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9
Q

(~90%)
From HYPOPERFUSION
Older adults, pt with DM
Non-Lacunar: large vessel dx including carotids
Atherosclerosis most common cause
Thrombosis: embolism
Common RF: afib, valve replacement, recent MI

A

ischemic stroke

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10
Q

small vessel dx (intracerebral arterial system, distal vertebral and basilar arteries)

A

Lacunar: (ischemic stroke)

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11
Q

Immediate CVA stroke management

A

ED for CT w/o contrast to r/o hemorrhagic; IV thrombolytic therapy (TPA) within 6 hours of sx onset → best result within 3 hours, time is brain! Mechanical thrombectomy

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12
Q

Primary care role post CVA

A

1st visit should be soon after d/c from acute care/rehab within 1-3 wks
Screen for: complications
continue antiplatelet
Screen at ALL apt for stroke RFs

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13
Q

An acute fluctuating syndrome of altered attention, altered awareness and cognition in the patient
Commonly found in older persons in hospital or long term care settings
May indicate a life threatening condition

A

Delirium

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14
Q

3 forms of Delirium

A

Hyperactive= Confusion, agitation, hallucinations, myoclonus

Mixed= Fluctuates between both

Hypoactive = Confusion, somnolence, withdrawn

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15
Q

amyloid plaque and neurofibrillary tangles. Atrophy of cerebral cortex.
Earliest sign: short term memory loss

A

Alzheimer - dementia

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16
Q

multiple areas of focal ischemic change

A

vascular dementia

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17
Q

proteins that enter neurons and cause cell degeneration and death. Loss of dopamine producing neurons (like parkinson) and loss of acetylcholine (like Alzheimer)
present with visual hallucinations, motor impairments, postural instability, and sleep disturbances
Increase sensitivity to neuroleptics: haloperidol

A

Lewy body Dementia

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18
Q

2 or more brain functions (typically memory loss and language skills) impaired without a loss of consciousness

A

Dementia

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19
Q

depression in older adults leading to memory loss, attention deficits, and problems with initiation

A

Pseudodementia

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20
Q

Dx Dementia

A

MMSE- > 24-30: no impairment; 18-23: mild impairment; 0-17 severe impairment
Clock drawing, mini cog, geriatric depression test, remember words
cognitive testing

Thorough history/neuro exam; assess ADLs (Have fam member present for evaluation)

Labs: CBC, CMP, TSH, B12, folate, Ca***
Non contrast CT or MRI- recommend a baseline brain imaging
Additional tests: neuroimaging, CSF analysis, lyme tite, RPR

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21
Q

Pharm tx for dementia

A

Acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine)
Memantine (namenda)
SSRI for depression

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22
Q

Nonpharm tx for dementia

A

Cognitive training; lifestyle behavioral interventions; exercise; educational interventions; multidisciplinary interventions; shared group visits

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23
Q

group of monophasic immune mediated peripheral neuropathies
Demyelinating neuropathy
Acute inflammatory polyradiculoneuropathy
Miller Fisher syndrome- oculomotor nerve myelin affected
Axonal: axon is targeted rather than myelin sheath. Most common.

A

Guillain-Barre Syndrome

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24
Q

⅔ of the time follow an upper respiratory or gastrointestinal infection
Common virus: CMV and EBV
Bacteria: Campylobacter jejuni (23% to 45%), Mycoplasma pneumoniae (5%), and Haemophilus influenzae.

A

GBS

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25
Q

clinical presentation of GBS

A

Symmetric paresthesia and weakness starting in the LOWER extremities and evolving over hours to days…Weakness spread to upper extremities/ deep tendon reflexes, then respiratory muscles, and finally paralysis
Weakness peaks at 3 WEEKS

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26
Q

incoordination in extremities and weakness of eye movements with double vision. Recover more quickly and completely. Areflexia, ataxia, and distal paresthesia.

A

MFS (Miller Fisher Syndrome)

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27
Q

form of GBS preserved reflexes and tend not to have pain

A

Acute Motor Axonal Neuropathy (AMAN

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28
Q

Most important confirmatory test for GBS

A

LUMBAR PUNCTURE

Albuminocytolic dissociation: elevated CSF protein with some increase of mononuclear CSF WBC
acutely : polymorphonuclear leukocytes

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29
Q

Tx of GBS

A

hospitalization: monitor progressive weakness, provide supportive care, and manage potential complications

Immunologic treatment:
IVIG or plasma exchange - reduces the duration of mechanical ventilation and hastens recovery
Corticosteroids are NOT indicated

Evaluate strength using 5 point Medical Research Council scale
Physical, occupational, and speech therapy

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30
Q

_____ metastases are more prevalent in non-SCLC and breast cancer due to the higher incidence

A

Brain

Astrocytoma (20.3%) 
Oligodendroglioma (1.4%)
Ependymoma (1.8%)
Meningioma (36.8%)
Primary CNS lymphoma (2 %)
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31
Q

Peritumoral edema- risk for brain herniation
Seizure common presenting symptom
glioblastomas = fast growing tumors will show abrupt symptoms
Focal changes = deficits in vision, speech, strength, sensation, or gait
Nonfocal= headache, memory loss, behavior change, cognitive deficits and fatigue
Papilledema= may indicate increased intracranial pressure

A

CM of intracranial tumors

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32
Q

physical exam for intracranial tumors

A

Occipital and parietotemporal: visual field testing
Frontal or parietal lobe: motor and sensory abnormalities
Frontal or temporal lobe: aphasia
Posterior fossa- gait dysfunction or disorders of coordination

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33
Q

Dx for intracranial tumors

A

CT head with contrast
Brain MRI with or without contrast (with gadolinium is gold standard) ***

Tissue acquisition- to establish diagnosis and render treatment
Concern for metastatic disease- CT scan of chest, abdomen, and pelvis or PET scan

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34
Q

Chronic, progressive, inflammatory neurodegenerative dx that affects the CNS
Hallmark lesion: Plaque

Patients at high risk for other autoimmune disorders: DM, RA, osteoporosis, frequent UTI, obesity, depression, and thyroid disease

A

MS

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35
Q

Some neuro sx, lasts ~24 hours, 1st one experienced, typically no diagnosis yet
Would see maybe 1 lesion on MRI if obtained
Most in CIS have 60-80% of full blown case in next 5 yrs

A

Clinically isolated syndrome (CIS)

1st course/ event of MS

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36
Q

Most common course; 85% diagnosed in this category
attacks/periods of sx → get better/resolve → cyclical
NO progression; episodic cases of sx
Typically 20’s-30’s; can stay in this course for a while (~10 ye

A

Relapsing-remitting MS (RRMS)

37
Q

Attacks causing nerve damage; dx worse → damage staying
Proressive damage to nerves
Can be gradual transition from RRMS to SPMS

A

Secondary-Progressive MS (SPMS)

38
Q

Worsening neuro function from beginning of symptoms
Start here and stay here!
40’s-50’s typically when seen; already have permanent nerve damage
More difficulty with walking, working, performing ADLs

A

Primary-Progressive MS (PPMS)

39
Q

electrical shock sensation down spine when bending neck forward

A

Lhermitte’s sign

can be MS sign

40
Q

tightening sensation around torso; can feel very restricting

A

Dysesthesia (“MS hug”)

41
Q

Multiple Sclerosis exam?

A

Mental status, neuro (eyes: EOMs, nystagmus; fundoscopic exam; trigeminal neuralgia; CN 7 dysfunction; sensory; romberg; cerebellar; reflexes), MS
Documented neurologic and functional baseline for evaluation of response to treatment or possible exacerbation of disease

42
Q

Multiple Sclerosis diagnostics?

A 
Clinical diagnosis
MRI with gadolinium = gold standard for diagnosis of MS via the McDonald criteria
CSF analysis (oligoclonal bands)
Final diagnosis done by neurology by McDonald criteria

Refer to neurologist, MS neurology expert, or MS center for confirmation of diagnosis

43
Q

For MS… Incidents defined by time and space
Episode lasting 24 hours, 30 days apart (time)
Evidence of 2 locations affected (space)
Also need NO other reason for patient’s sx

A

McDonald Criteria

44
Q

Multiple Sclerosis management?

A

Goal of therapy: reduce # of attacks and progression of disease + sx management
DMT initiation starts as early as possible with the first presentation of, usually, CIS.

The use of DMTs is not recommended during pregnancy or while breastfeeding.
Stop three months before conceiving

Exacerbation treatment: high-dose intravenous steroids for a short period or adrenocorticotropic hormone (ACTH)
Lifestyle modifications: A low-sodium diet and smoking cessation

45
Q

autoimmune disorder that produces an immune-mediated neuromuscular blockade or neuromuscular junction disorder …

circulating receptor binding antibodies decrease the number of available acetylcholine receptors on the postsynaptic muscle membrane or motor end plate, leaving the motor end plate less responsive

A

Myasthenia Gravis

46
Q

symptoms are permanent, no remission, but does not experience myasthenic crisis
Respiratory insufficiency, dysphagia, hypotonia, weakness, poor spontaneous motor activity, weak cry, poor sucking, choking, expressionless face, and absent Moro reflex.

A

Congenital Myasthenia Gravis

47
Q

1st symptom of MG

followed by…

A

Ptosis or extraocular muscle weakness

double vision, fatigue when chewing, slurred speech, snarling appearance when smiling, weakness of limb girdle and distal muscles of hands.

48
Q

In Myasthenia Gravis… Rapid muscular fatigue as evidenced by inability to:

A
  • Hold an upward gaze for 30 to 90 seconds
  • Sustain a chin to chest position while supine
  • Maintain arm abduction for more than 1 to 2 minutes
  • Sustain rapid hand-fisting movements for long periods of time
49
Q

Diagnostics for Myasthenia Gravis

A

short-acting cholinesterase inhibitor (edrophonium chloride) is given as a clinical test (should cause spontaneous improvement in the ptosis ) ;
EMG
AchR antibody testing (often inconclusive)
thyroid profile
CK level (normal with MG); chest x-ray (any enlarged thymus needs to be followed up with a tomography or CT scan of the anterior mediastinum); ECG (should be normal); muscle biopsy may be considered.

50
Q

Tx for Myasthenia Gravis

A

Anticholinesterase therapy: Pyridostigmine
Treatment goals not met: corticosteroids or immunosuppressants therapy
Symptoms that are severely debilitating: corticosteroids, cytotoxic agents (azathioprine and cyclosporine) or thymectomy

51
Q

Complications r/t Myasthenia Gravis

A

Corticosteroid use- growth retardation
Thymectomy- immunodeficiency in adulthood
Long term therapy with anticholinergic- cholinergic crisis similar to myasthenic crisis
Myasthenic crisis: worsening muscle weakness, resulting in respiratory failure and requires a vent.

52
Q 
Cardinal features: (motor)
Tremor at rest (hands, fingers, forearms, feet)
Muscular rigidity
Akinesia (bradykinesia)
Reduced arm swinging
Shuffling gait with short steps
Masklike faces (expressionless)
Loss of postural reflexes
Flexed posture; forward tilt trunk
Other CM: fatigue, depression, sleep disturbance, dystonia, hypophonia, drooling, impaired cognition, dysphagia, dystonia
A

Parkinson’s Disease

53
Q

How to dx parkinsons

A

CLINICAL; thorough hx and neuro exam
Positive response to dopaminergic tx supports diagnosis (levodopa)
Must have 3 supporting sx
Typically unilateral onset with persistent asymmetry
Presence of tremor at rest
Gradual sx progression
No lab test indicated
CT/MRI only if you suspect structural lesion → do not confirm PD diagnosis

54
Q

Primary Pharm tx for parkinsons

A

Gold standard: levodopa + carbidopa

Goal: neuroprotective tx

55
Q

sense of inner general restlessness reduced or relieved by moving about
= inability to remain still.

A

Akathisia

56
Q

brief flap of outstretched limb, transient inhibition of the muscles of posture

A

Asterixis

57
Q

unsteady or swaying motion

A

Ataxia

58
Q

slow, writing, continuous, involuntary movement

A

Athetosis

59
Q

involuntary, irregular, nonrhythmic movements that seems to flow from one body part to another

A

Chorea

60
Q

abnormal involuntary movement

A

Dyskinesia

61
Q

A sustained involuntary muscle contraction that results in twisting movement and posture, often patterned and repetitive.

A

Dystonia

62
Q

Sudden, irregular, involuntary jerking of the muscles.

A

Myoclonus

63
Q

A fine quivering or rippling of muscles. Common and benign in facial muscles.

A

Myokymia

64
Q

A coordinated movement that repeats continually and identically. Compulsion.

A

Stereotypy

65
Q

An oscillation, usually rhythmic and regular

A

Tremor

66
Q

most common movement disorder

Can be caused by my meds, psych, substances, etc; rule everything out!

A

essential tremor

67
Q

Akinetic, hypokinetic, or bradykinetic syndromes (parkinson disease, depression, hypothyroidism)

A

​​Insufficient Movement

68
Q

Myoclonus, encephalopathy, chorea (Huntington disease) , and tic disorders (Tourette syndrome, complex partial seizures)

A

Too Much Movement “Jerky”

69
Q

Dystonia and tremor (essential tremor, metabolic disorders, medication, genetic, stroke, MS, tumor)

A

Non-jerky movement

70
Q

diagnostics for Movement disorders

A

Clinical diagnosis
Initial studies: CBC with differential, CMP, and thyroid studies to r/o medical or metabolic abnormalities
Infection workup: CBC, urinalysis, chest xray
Drug or alcohol: toxicology screen, ammonia level, LFTs
Neurologic findings: CT scan of head

71
Q

Criteria for dx movement disorder

A
  • Tremor of the hands and forearms or at least one arm (postural or kinetic tremor)
  • Detailed hx regarding tremor, fam hx, social hx (alcohol, caffeine, drug use) and meds
  • Absence of other neuro signs/etiologies (Parkinsonism, dystonia, alcohol, meds)
72
Q

Essential tremor: Pharm management 1st =

2nd=
other

A

1st Propranolol
Reevaluated propranolol after 1-2 weeks

Anticonvulsant (Primidone) next option if beta blockers are not effective and can be in combined therapy with propranolol
clonazepam/alprazolam can be used with caution

Atenolol, gabapentin, sotalol, topiramate considered for limb tremor

73
Q

Essential Tremor: Nonpharm

A

Surgical deep brain stimulation, focused ultrasound ablation, radio frequency ablation, and stereotactic radiosurgery
Alcohol

Avoid stimulants such as caffeine, soda, and coffee, OTC allergy and cold preparation
Screen for alcohol abuse

74
Q

Distressing “creepy-crawly” sensation in the legs. Irresistible urge to move the extremities.
Can cause chronic insomnia

familial , idiopathic, or associated with disorders (pregnancy, renal failure, and low iron stores ferritin levels < 75 or transferrin < 17) (also peripheral neuropathy and parkinson disease)

A

RLS

75
Q

RLS has four principal diagnostic criteria.

A
  1. Urge to move the legs, uncomfortable sensation
  2. Urge begins or worsens during inactivity or rest
  3. Ameliorated by activity or movement such as stretching or walking
  4. Urge or sensation are worsened in evening or at night
76
Q

diagnostics for RLS

A

IRON STATUS- associated with RLS
Fasting serum iron, total iron binding capacity, ferritin, and transferrin saturation
RLS is clinical diagnosis
PSG may offer supportive information of the diagnosis

77
Q

pharm tx for RLS

A

First line***** and may help with neuropathy= Alpha 2 delta ligands- gabapentin, pregabalin, and gabapentin enacarbil (only FDA approved for RLS)

First line in patients with concomitant depression or who is at higher risk for falls = Dopamine agonist: pramipexole, rotigotine, and ropinirole

Screen for impulse control disorder
Opioids, carbamazepine, and clonidine
Supplement iron

78
Q

genetic neurodegenerative disorder characterized by developmental arrest and regression and multisystem comorbidities
Mutation in the X-linked, methyl- CpG=binding protein 2 (MECP2) gene
Also: CDKL5 and FOXG1 genes

A

Rett Syndrome

79
Q

Early red flag- head growth deceleration
Seizures, scoliosis, sleep disturbance, GI dysfunction, resp dysfunction
bruxism, apraxia, gait abnormalities, and stereotypic hand movements (e.g., wringing/squeezing, clapping/tapping, hand-mouthing or biting and handwashing/rubbing automatisms).

A

Rett Syndrome

80
Q

main criteria for dx rett syndrome

A

consider diagnosis when postnatal deceleration of head growth is observed.
Based on main criteria
- Partial or complete loss of acquired purposeful hand skills.
- Partial or complete loss of acquired spoken language**
- Gait abnormalities: Impaired (dyspraxic) or absence of ability.
- Stereotypic hand movements such as hand wringing/squeezing, clapping/tapping, mouthing and washing/rubbing automatisms

Due to risk for seizures: screening EEG is advised with diagnosis

81
Q

Complex neuro disorder with uncontrolled electrical disturbance in the brain
Single seizures: high fever in small children, hyponatremia, hypercalcemia, hyperventilation in susceptible patients, or alcohol withdrawal.

A

Seizures

82
Q

continuous convulsive seizure for five minutes, continues focal seizure for 10 minutes, and continuous absence seizure for 10-15 minutes

A

status epilepticus

83
Q

when to dx epilepsy

A

after 2 or more seizures that are not brought on by an identifiable cause

Generalized: affect both sides of the brain
Focal: partial seizures; located in one area of the brain

84
Q

When should you call 911 with seizure

A

1st seizure; difficulty breathing/waking after seizure; >5min; another seizure soon after 1st; pt hurt during seizure; happens in water; comorbidities (DM, heart dx, pregnant)

85
Q

Seizure pharm management

A

Levetiracetam (Keppra); Fosphenytoin/phenytoin (Cerebyx); Valproic acid (depakote), Lamotrigine (Lamictal)

When medications are changed, the new medication should be added to the existing regimen. When the new medication is well tolerated and an effective dose has been achieved, the first medication can be slowly reduced.

86
Q

caudal end is fixed by a ropelike filum terminale at or below the L2 level

Associated with congenital spinal anomaly: spina bifida
Result from: bony protrusions, tough membranous bands, lipomas, tumors, trauma in the cauda equina

A

Tethered Cord

87
Q

Gold standard dx for tethered cord

tx?

A

MRI of spine

refer to neurosurgeon

hx of repaired spina bifida must closely be monitored for tethered cord

88
Q

CM of Tethered Cord

A

not all leads to symptoms
Lesions, hairy patches, dimples, or fatty tumors on the lower back; foot and spinal deformities; weakness in the legs; low back pain; scoliosis; and incontinence

89
Q

Benign, chronic neurologic condition that involves symmetric, rhythmic trembling of the upper extremities, head, or voice.
Emotion stress increase symptoms and alcohol decrease symptoms

A

essential tremor

FNP III - Test 1 (6 decks)

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