Neruology Flashcards
What are the red flags for headache?
New onset >50 yrs old
Sudden Thunderclap
Worse with position
Sudden onset after exerting (coughing, straining)
Focal Neuro findings- papilledema, change LOC, CN abnormalities
In addition to history of sudden severe, “worse headache of my life,” what history and exam findings support the concern for SAH?
Nausea & vomiting, neck pain, hypertension, tachycardia, with or without focal neuro findings.
Older patient with new onset of headache in one temple accompanied by scalp tenderness with finding of inflammation over temporal area is likely what condition?
Temporal arthritis (giant call arthritis)
What labs would likely be elevated increasing the suspicion for temporal arthritis?
ESR, Sed rate, and CRP.
T/F, hemorrhagic stroke is more common than thrombotic?
False, thrombotic accounts for almost 90% of strokes
T/F in subdural hematoma, blood collection is found deep in the intracranial tissues?
False, blood collects between dura and subarachnoid membrane.
A wide-based gait that is uncoordinated is what type of gait and indicates what type of disorders?
Ataxic, cerebellar dysfunction
How is a tandom gait test performed?
Have patient walk placing one foot right in front of the other, positive test if they are unable or fall over.
What are the classic cerebellar tests and how are they performed?
Gait: observe coordination and stance with ambulation
1) . Tandem: one foot in front of the other
2) . Rapid alternating movements: place hands on top of other and rapidly alternate
3) . Heel-to-shin: patient runs heel down the shin of the opposing leg
4) . Finger-to-nose & finger-to-finger: Have patient touch your finger then their nose (move your position), Repeat finger to finger without moving
5) . Proprioception: Romberg test-Patient stands feet together, arms at side w/ eyes open (observe to positioning), then close eyes and continue to observe positioning. Positive sign is wide stance, excessive swaying or inability
What is sterognosis?
The ability to recognize by touch familiar objects
The ability to identify a number written on the palm is what?
Graphestheisa
When testing for pronator drift, the patient arm falls or lifts sideward/upward after brief tap is considered positive or negative?
Positive
T/F 4+ reflex is hyper-reflexive and noted as clonus?
True
Patellar tendon reflex assessed what spinal level?
L2/3/4/5
Bicep tendon reflex assessed what spinal level?
C5/6
Achilles tendon reflex assessed what spinal level?
S1/2
Tricep tendon reflex assessed what spinal level?
C6/7/8
When assessing for Kernig’s sign, how is it performed and what is a positive result?
Patient supine- raise leg with hip flexed, one at a time, then attempt to straighten leg. + if produces back pain or resistance
How is a positive Brudzinski’s sign demonstrated?
When examiner raises the neck, there is a reflexive flexion of the hips and knees (to relieve pressure)
A few small vesicular lesions on the tip of the nose and temple suggest what condition?
Shingles of the trigeminal nerve (CNV)
If the patient resists or has great pain flexing neck towards chest, what finding is that called?
Nuchal rigidity
T/F + Babinski sign is normal after 1 year?
False, only normal in a young infant
When evaluating a closed head injury, which cranial nerves should be closely examined?
CN II, CN III, CN IV, CN VI, and CN VII
What nuerological structures are often affected by multiple sclerosis?
CN II, spinal cord, brain stem, cerebellum and white matter
What are common presenting symptoms with multiple sclerosis?
Visual loss, diplopia, nystagmus, vertigo, balance issues, foot drop, numbness & paresthesia unilaterally on the face, bowel dysfunction, urinary incontinence.
Also may experience electrical shock like sensations down back when bending forward.
Prior to prescribing 5-HT-1 agonists (triptans), what must be ruled out?
Underlying cardiovascular disease
T/F migraine suffering patients generally respond well to SSRIs combined with 5-HT-1 agonist (triptans)?
False- SSRIs are contraindicated with triptans due to high risk of serotonin syndrome
T/F Imitrex is the drug of choice to prevent migraine headaches?
False- 5-HT-1 agonists (triptans) are abortive, not preventative
What drugs are considered appropriate migraine prophylactic agents?
Beta blockers- propranolol
TCAs- Amitriptyline (elavil)
Anticonvulsants- valproate and topiramate
SSNRI-Venlafaxine (Effexor) and
Migraine with brain stem aura presents in what manner?
patient exhibits signs of a stroke, except hemiplegia. Focal Neuro findings may include: visual disturbance, ataxia, dysarthria with bilateral tingling, and numbness to the face. Many lose consciousness for 2-30 minutes.
What is the first line treatment for temporal arthritis?
High dose steroids for many weeks
T/F temporal arthritis may present with unilateral blindness?
True
What laboratory finding with patient who is over 50 years old experiencing severe bilateral joint stiffness and aching, with pain to posterior neck, shoulder, upper arms and hips causing difficulty with actives such as dressing would support the diagnosis of polymyalgia rheumatica?
ESR and CRP
Patient with polymyalgia rheumatica are at for developing what disorder?
Temporal arteritis
A female patient complains of sudden onset of sharp and piercing unilateral face pain is suspicious for what disorder and what is the treatment?
Trigeminal neuralgia- high dose anticonvulsants such as carbamazepine (tegretol). Muscle relaxants are beneficial with tegretol as well
What diagnostic test should be ordered for a patient suspected to have trigeminal neuralgia and why?
MRI (or contrasted CT) to rule our tumor
What facial nerve is affected by Bell’s Palsy?
CN VII
T/F patients with Bell’s Palsy will have weakness on the contralateral eye and forehead?
False- unlike stroke, CN does not innervated to the other side. Symptoms are ipsilateral.
What is the treatment for Bell’s Palsy?
High-does steroids 60-80mg/day x7 days with taper, AND antiviral such as valacyclovir 1000mg tid or acyclovir
What should the NP teach a patient diagnosed with Bell’s Palsy to prevent this common associated issue?
Use of lubricating eye drops and ointment at night to prevent corneal abrasion due to eye dryness (inability to close)
What is the treatment for cluster headache?
High dose oxygen- may also give Imitrex w/ oxygen
What are some other adjunctive therapies for cluster headache sufferers?
Melatonin 10mg q hs to reduce headache frequency
Capcaisin ointment to ipsilateral nostril x 7 days
Patient presents with headache described as “band-like,” or feeling of being in a “vice grip” with absence of focal neurological signs is likely to have with type of headache and what is the treatment?
Tension- NSAIDS and/or acetaminophen
With headache management, why should the use OTC analgesic agents (NSAIDS and acetaminophen) be limited to less than 9 times a month?
Will cause rebound headache with regular and frequent use
ABCD2 score evaluates TIA risk, at what level should patients be referred to the ED?
3 or greater
What are the factors scored in ABCD2?
A- age >65 1point
B- BP >140/90 1point
C-Clinical features of TIA
unilateral weakness w/ and w/o speech impairment 2 point
Speech impairment w/o unilateral weakness 1 point
D: Duration
> 60 minutes 2 points
10-59 minutes 1 pointLeft MCA stroke produces what findings?
Right side weakness and broca’s aphasia (expressive)
R. MCA stroke produces what findings?
Left side weakness, hemineglect and possible hemiopia
According to AHA, what is the window for administration of with thrombotic (ischemic) stroke?
4.5 hours
What is the greatest risk for patients who suffer from cluster headaches?
Suicide
What is the common headache that presents with bilateral pain?
Tension
When eliciting babinski reflex on an adult, what would be a negative and a positive finding?
Negative- plantar flexion is normal
Positive- dorsiflexion if the great toe
What dermatomal level is the umbilicus?
T10
What anterior landmark denotes T4 dermatomal level?
Lower sternal border at nipple level
What dermatomal level is the rectum?
S4 & S5
