Nervous System Flashcards

Question 1

Q

Danger Signals

Dangerous H_____

_______Hemorrhage

Acute Bacterial M_____ (In Adults)

Acute S_____(Cerebrovascular Accident)

Chronic S______ Hematoma

Multiple ______

Answer

A

Dangerous Headaches

Subarachnoid Hemorrhage

Acute Bacterial Meningitis (In Adults)

Acute Stroke (Cerebrovascular Accident)

Chronic Subdural Hematoma

Multiple Sclerosis

Question 2

Q

Dangerous Headaches

Th________ headache (very severe headache that reaches maximum intensity in 1 minute or less)

“____ headache of my ____”

First onset of headache at age ____ years or older

Sudden onset of headache after coughing, exertion, straining, or sex (________ headache)

Answer

A

Thunderclap headache (very severe headache that reaches maximum intensity in 1 minute or less)

“Worst headache of my life”

First onset of headache at age 50 years or older

Sudden onset of headache after coughing, exertion, straining, or sex (exertional headache)

Question 3

Q

Dangerous Headaches

Sudden change in level of _________

_____ neurologic signs (e.g., unequal p____ size, hemipar____, loss of function, poor gag reflex, difficulty swallowing, ____asia, sudden vision loss, v_____ field defect)

Headache with p_____ (increased intracranial pressure [ICP] secondary to any of those listed here) - next card

Answer

A

Sudden change in level of consciousness (LOC)

Focal neurologic signs (e.g., unequal pupil size, hemiparesis, loss of function, poor gag reflex, difficulty swallowing, aphasia, sudden vision loss, visual field defect)

Headache with papilledema (increased intracranial pressure [ICP] secondary to any of those listed here)

Question 4

Q

Dangerous Headaches

“Worst-case” scenario of headaches (rule out) includes the following:

(2) hemorrhages
Leaking an______ or (1) (AVM)
Bacterial m______
Increased I _ _
Brain ab_____
Brain t_____

Answer

A

Subarachnoid hemorrhage (SAH) or acute subdural hemorrhage
Leaking aneurysm or arteriovenous malformation (AVM)
Bacterial meningitis
Increased ICP
Brain abscess
Brain tumor

Question 5

Q

Subarachnoid Hemorrhage

Onset =

Description of headache =

Accompanying symptoms = n____/v____, n___ pain or stiffness (positive (2) signs), _____phobia, and v_____ changes (diplopia, visual loss), and a rapid decline in _ _ _

Answer

A

Sudden and rapid onset of severe headache described as

“the worst headache of my life”

accompanied by nausea/vomiting, neck pain or stiffness (positive Brudzinski and/or Kernig signs), photophobia, and visual changes (diplopia, visual loss) with a rapid decline in LOC.

Question 6

Q

Subarachnoid Hemorrhage

The headache may be nonlocalized or localized in the occ_____ area and n____

May have se_____ during the acute phase.

Vital signs reveal blood pressure (BP) ____, temperature _____, and ____cardia.

Depending on the source of the bleed, may have f_____ neurologic signs or no signs.

Answer

A

The headache may be nonlocalized or localized in the occipital area and neck.

May have seizures during the acute phase.

Vital signs reveal blood pressure (BP) elevation, temperature elevation, and tachycardia.

Depending on the source of the bleed, may have focal neurologic signs or no signs.

Question 7

Q

Subarachnoid Hemorrhage

Usually caused by ruptured (1) or (1)

A “______ headache” (sudden intense headache) can precede a spontaneous SAH by days to weeks.

An unenhanced (1) scan can detect an SAH in approximately 95% of patients within first 24 hours.

About 22% of patients die on the same day. A medical _____. Call ___.

Answer

A

Usually caused by ruptured cerebral aneurysm or AVM.

A “sentinel headache” (sudden intense headache) can precede a spontaneous SAH by days to weeks.

An unenhanced CT scan can detect an SAH in approximately 95% of patients within first 24 hours.

About 22% of patients die on the same day. A medical emergency. Call 911.

Question 8

Q

Acute Bacterial Meningitis (In Adults)

Who is at highest risk for this life-threatening infection? (3)

Community-acquired bacterial meningitis is most commonly due to (1) (50%) and (1) (30%).

Acute onset of high f_____, severe h_____, ____ neck (1), and meningismus with altered _____ status.

Answer

A

Neonates, infants, and elderly are at highest risk for this life-threatening infection.

Community-acquired bacterial meningitis is most commonly due to Streptococcus pneumoniae (50%) and Neisseria meningitides (30%).

Acute onset of high fever, severe headache, stiff neck (nuchal rigidity), and meningismus with altered mental status.

Question 9

Q

Acute Bacterial Meningitis (Adults)

Classic p_____ pe_____ rashes appear. Accompanied by n____, v____, and _____phobia. Rapid worsening of symptoms progressing to lethargy, confusion, and finally c_____. If not treated, fatal. Bacterial meningitis is a medical emergency. Call 911.

Answer

A

Classic purple petechial rashes appear. Accompanied by nausea, vomiting, and photophobia. Rapid worsening of symptoms progressing to lethargy, confusion, and finally coma. If not treated, fatal. Bacterial meningitis is a medical emergency. Call 911.

Question 10

Q

Acute Stroke (Cerebrovascular Accident)

Classified as either (1) (87%) or (1) (13%).

Risk factor(s) for embolization

(e.g., atrial _____, prolonged imm_____) presents with acute onset of stuttering/sp____ disturbance, one-sided facial _____ , and one-sided weakness of the arms and/or legs (______).

Risk factors for hemorrhagic stroke

often have poorly controlled _____ and present with the abrupt onset of a severe ______, nausea/vomiting, and nuchal rigidity (_____ bleed). Call 911.

Answer

A

Classified as either embolic (87%) or hemorrhagic (13%).

Risk factor(s) for embolization

(e.g., atrial fibrillation, prolonged immobilization) presents with acute onset of stuttering/speech disturbance, one-sided facial weakness, and one-sided weakness of the arms and/or legs (hemiparesis).

Risk factors for hemorrhagic stroke

often have poorly controlled hypertension and present with the abrupt onset of a severe headache, nausea/vomiting, and nuchal rigidity (subarachnoid bleed). Call 911.

Question 11

Q

Chronic Subdural Hematoma

=

Chronic subdural hematoma (SDH) presents gradually, and symptoms may not show until a few weeks after the injury. Patient with a history of head _____ (falls, accidents) presents with a history of head_____ and gradual c_____ impairment (apathy, somnolence, confusion). More common in al____, the el_____, and those who are on anti_____ or aspirin therapy.

Answer

A

Bleeding between the dura and subarachnoid membranes of the brain.

Chronic subdural hematoma (SDH) presents gradually, and symptoms may not show until a few weeks after the injury. Patient with a history of head trauma (falls, accidents) presents with a history of headaches and gradual cognitive impairment (apathy, somnolence, confusion). More common in alcoholics, the elderly, and those who are on anticoagulation or aspirin therapy.

Question 12

Q

Multiple Sclerosis

Adult (1) gender complains of episodic v_____ loss or _____ (double vision), problems with bal____ and w_____, and ______ness and paresthesias on one side of the _____.

Accompanied by urinary ______ (75%) and/or bowel dysfunction (50%). Reports that when bending neck forward/flexion, an (1)-like sensation runs down the back ((1) sign). Not emergent, but recognization of presenting signs and symptoms is important

Answer

A

Adult female complains of episodic visual loss or diplopia (double vision), problems with balance and walking, and numbness and paresthesias on one side of the face.

Accompanied by urinary incontinence (75%) and/or bowel dysfunction (50%). Reports that when bending neck forward/flexion, an electric shock-like sensation runs down the back (Lhermitte sign). Not emergent, but recognization of presenting signs and symptoms is important

Question 13

Q

(1)

Acute onset of headache that is located on one temple of an older patient (average age 70 years).

Some will complain of this instead of a headache?
Affected temple presentation =
Visual symptoms =
Jaw symptoms =
Labs will show elevated (2)

Answer

A

Giant Cell Arteritis (Temporal Arteritis)

Some will complain of excruciating burning pain over the affected temporal artery instead of a headache.
The affected temple has an indurated, reddened, and cord-like temporal artery (tender and warm to the touch) that is accompanied by scalp tenderness.
Abrupt onset of visual disturbances and/or transient blindness of affected eye (amaurosis fugax).
Some may complain of jaw pain or jaw claudication (caused by artery obstruction).
Markedly elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

Question 14

Q

Giant Cell Arteritis (Temporal Arteritis)

Patients with (1) are at very high risk of developing temporal arteritis (up to 30%),

And the headache may be accompanied by symptoms of PMR, such as fever, pain on the sh_____ and h____ (polymyalgia), anorexia, and _____ loss. If untreated, temporal arteritis will lead to bilateral _______.

Answer

A

Patients with polymyalgia rheumatica (PMR) are at very high risk of developing temporal arteritis (up to 30%),

And the headache may be accompanied by symptoms of PMR, such as fever, pain on the shoulders and hips (polymyalgia), anorexia, and weight loss. If untreated, temporal arteritis will lead to bilateral blindness.

Question 15

Q

Folstein Mini-Mental State Exam (MMSE)
Assesses 5 things

(1)
1. (name, age, address, job, time/date/season)
Registration
1. (1)*
Attention and calculation
1. (1)*
Recall
1. (1)*
(1)
1. While speaking to patient, look for aphasia (impairment in language resulting in difficulty speaking)

Answer

A

Orientation
1. (name, age, address, job, time/date/season)
Registration
1. (Recite three unrelated words. Distract patient for 5 minutes, then ask the patient to repeat the words.)
Attention and calculation
1. Spell world backward or indicate serial 7s (subtract 7 starting at 100)
Recall
1. Ask for the names of the three objects learned earlier
Language
1. While speaking to patient, look for aphasia (impairment in language resulting in difficulty speaking)

Question 16

Q

(1)

Testing the part of the brain that coordinates unconscious regulation of balance, muscle tone, and coordination of voluntary movements

Gait =*
Positive =
Tandem gait =*
Positive =

Answer

A

Cerebellar Testing

Gait:* Tell patient to walk to the other side of room and back. If use of walking aid (e.g., cane, walker), test patient with the walking aid. Observe gait—is patient shuffling, scissoring, waddling, or swinging?
Positive: If acute cerebellar ataxia, patient will have a wide-based staggering gait.
Tandem gait:* Tell patient to walk a straight line in normal gait, then instruct patient to walk in a straight line with one foot in front of the other.
Positive: Test is positive if patient is unable to perform tandem walking, loses balance, and falls.

Question 17

Q

Cerebellar Testing Cont.

Rapid alternating movements =*
Positive =
Heel-to-shin testing =*
Positive: =
Finger-to-nose and finger-to-finger test =*
Positive =

Answer

A

Rapid alternating movements:* Tell patient to place hands on top of each thigh and move them (alternating between supination and pronation) as fast as possible.
Positive: Patient unable or problems with rapid alternating movements (dysdiadochokinesia).
Heel-to-shin testing:* Patient is in a supine position with extended legs. Tell patient to place the left heel on the right knee and then move it down the shin (repeat with right heel on left knee).
Positive: Unable to keep their foot on the shin.
Finger-to-nose and finger-to-finger test:* Tell patient to fully extend arm, then touch their nose or ask them to touch their nose, then extend arms and touch your finger.
Positive: Patient unable or misses touching nose and/or finger to nose (dysmetria).

Question 18

Q

Test for Proprioception

(1)

How to perform the test?

What is a positive test?

Answer

A

Romberg test:

Tell patient to stand with arms/hands straight on each side and with feet together with eyes open and observe. Next, instruct patient to close both eyes while standing in the same position and observe.

Positive:* Test is positive if patient sways excessively, falls down, or has to keep feet wide apart to maintain balance. If abnormal, it is neuropathy or posterior column (of spine) disease
Proprioception, otherwise known as kinesthesia, is* your body’s ability to sense movement, action, and location

Question 19

Q

Clinical Pearls

Clinical findings that are highly suggestive of damage to the cerebellum are

_____ (poor muscle contrl that causes clumsy voluntary movements)
dis_____ as manifested by a ____-based gait
muscular ____tonia

Answer

A

ataxia
disequilibrium as manifested by a wide-based gait
muscular hypotonia

Question 20

Q

Cranial Nerves Pneumonic

Oh Oh Oh To Touch And Feel Very Green Vegetables AH!

Answer

A

Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Accessory (spinal accessory)
Hypoglossal

Question 21

Q

Cranial Nerve 1 Testing

Name of Nerve

Test

Answer

A

Olfactory

Blocking one nostril at a time, use a familiar scent (coffee, peppermint, etc)

Question 22

Q

Cranial Nerve 2 Testing

Name of Nerve

Test (2)

Answer

A

Optic

Visual field testing:* Patient stands about 2 feet in front of examiner and covers their left (or right) eye. Stretch arm so that it is in the peripheral visual field, and ask patient if they see one, two, or three fingers (all four quadrants). Stare straight ahead at about the same level as the patient (examiner serves as the “control”).
Snellen Chart =* Check central distance vision using Snellen chart (patient stands 20 feet away from chart)

Question 23

Q

Cranial Nerve 3, 4, 6 Testing

Name of Nerves

Test

(usually tested together)

Answer

A

CN3 Oculomotor

Moves eyes medially and downwards through (medial and inferior rectus muscles)

CN4 Trochlear

lifts eyes to look down

CN6 Abducens

moves eyes outward

EOMS

First look for ptosis. Stand about 2 feet in front of patient as they fixate gaze on the fingers of examiner’s hand. Instruct patient to “follow my fingers,” while observing for nystagmus (horizontal quick movements of eye in one direction, alternates with slower movements of eyes in opposite direction). Test pupillary function.

Question 24

Q

CNV Testing

Name of Nerve

Test

Answer

A

Trigeminal

Provides the sensory nerves to the face. Test sensation by lightly touching the forehead area, cheek, and chin. Trigeminal nerve has three branches: the ophthalmic (V1), cheek (V2), and jaw area (V3; Figure 1). Tell patient to close eyes when testing; ask if they can feel the sensation.

Question 25

Q

CN VII Testing

Name of Nerve

Test (3)

(1) = condition where there is inflammation of the facial nerve (motor portion) where the affected side of the face will not move

Answer

A

Facial

Close eyes tightly, look up and wrinkle forehead, smile - look for asymmetry and muscle atrophy

Bell’s Palsy = condition where there is inflammation of the facial nerve (motor portion) where the affected side of the face will not move

Question 26

Q

CN VIII Testing

Name of Nerve

Tests (2)

Answer

A

Vestibulocochlear (Acoustic)

Rubbing fingers or whispering words

Hearing exam can be done by rubbing patient’s hair in front of the ear. Alternative is to hold hand up as a sound screen, then whisper a few numbers, and ask the patient if they heard the words.

Question 27

Q

CN IX and X Testing

Name of Nerves

Tests (3)

Answer

A

Glossopharyngeal, Vagus

Both control the palate

Test = Open mouth and yawn, tongue blade to test gag reflex, and assess voice clarity

Observe for asymmetry when yawning, uvula should be midline, assess voice clarity and rule out dysarthria

Question 28

Q

CN XI Testing

Name of Nerve

Tests (2)

Answer

A

Accessory (Spinal Accessory)

Shoulder shrug and head rotation (rotate left to right/against hand)

Check sternocleidomastoid muscle for atrophy or asymmetry.

Question 29

Q

CN XII Testing

Name of Nerve

Test

Answer

A

Hypoglossal

Controls tongue movement

Stick out tongue and move side to side - look for atrophy and asymmetry

Question 30

Q

Exam Tips

(1):* Innervates movement of soft palate (ask patient to yawn or say “aah” to check voice clarity).
(1):* The number reminds you of the shoulders shrugging together.
(1):* Innervates the tongue (midline, no atrophy).

Answer

A

CN IX (9):* Innervates movement of soft palate (ask patient to yawn or say “aah” to check voice clarity).
CN XI (11):* The number reminds you of the shoulders shrugging together.
CN XII (12):* Innervates the tongue (midline, no atrophy).

Question 31

Q

Exam Tips

Herpes zoster infection (______) of CN ____ ophthalmic branch can result in corneal _____.

Rash at tip of nose and the temple area: Rule out _____ infection of the trigeminal nerve involving the ______ branch (V__).

Answer

A

Herpes zoster infection (shingles) of CN V (5) ophthalmic branch can result in corneal blindness.

Rash at tip of nose and the temple area: Rule out shingles infection of the trigeminal nerve involving the ophthalmic branch (V1).

Question 32

Q

Sensory System Testing

Closed Eyes for all these tests

(5)

Answer

A

Vibration sense:*
Sharp–dull touch:*
Temperature*
Stereognosis* (Ability to Recognize Familiar Object Through Sense of Touch Only)
Graphesthesia* (Ability to Identify Figures “Written” on Skin)

Question 33

Q

Vibration sense

What tool do you use?

How to perform the test?

Important test for assessing severity of what sensory condition?

Answer

A

128-Hz tuning fork

Tap the fork lightly, then place one end into the distal joint of each thumb, tips of toes, soles of feet comparing right to left sides for numbness/decreased vibration sense

Assess severity of diabetic peripheral neuropathy

Question 34

Q

Sharp–dull touch:

Tools you can use (2)

How to perform the test

Which sensory test is the earliest to be affected in disease (peripheral neuropathy/vitamin B12 deficiency anemia) - Vibration or Sharp Dull Touch?

Answer

A

Safety pin, toothpick

Use the sharp end of a safety pin or toothpick for sharp and head of safety pin or eraser end of a pencil to test dull sensation

Vibration sense often the earliest to be affected

Question 35

Q

Stereognosis

=

Test (1)

Graphesthesia

=

Test (1)

Answer

A

Stereognosis

(Ability to Recognize Familiar Object Through Sense of Touch Only)

Place a familiar object (e.g., coin, key, pen) on the patient’s palm and tell the patient to identify the object with eyes closed.

Graphesthesia

(Ability to Identify Figures “Written” on Skin)

“Write” a large letter or number on the patient’s palms using fingers (patient’s eyes are closed).

Question 36

Q

Motor Exam

Upper extremities:* Tell patient to ____ both arms in front of them, then p____ and s_____ . Tell patient to b____ and ex_____ forearms, then push against _______ provided by examiner.
Hands:* Perform full range of ____ with hands and fingers, without and with resistance (by examiner). The dominant hand will be slightly larger due to more muscle development.

Answer

A

Upper extremities:* Tell patient to raise both arms in front of them, then pronate and supinate. Tell patient to bend and extend forearms, then push against resistance provided by examiner.
Hands:* Perform full range of motion with hands and fingers, without and with resistance (by examiner). The dominant hand will be slightly larger due to more muscle development.

Question 37

Q

Motor Exam

Lower extremities:* While in _____ position, tell patient to flex each ___, then raise each ____ separately while the examiner provides _____. Compare legs.
Feet:* Perform full range of _____ on toes and ankles; examiner provides resistance.

Gross examination (legs) and fine motor movements (hands). Test w_____, using hands for manipulation/_____ grasp, j_____ and so forth.

Answer

A

Lower extremities:* While supine, tell patient to flex each hip, then raise each leg separately while the examiner provides resistance. Compare legs.
Feet:* Perform full range of motion on toes and ankles; examiner provides resistance. (gas pedal, up towards nose?)

Gross examination (legs) and fine motor movements (hands). Test walking, using hands for manipulation/pincer grasp, jumping, and so forth.

Question 38

Q

Pronator Drift Test*
=*

Answer

A

Have patient stretch out the arms with palms facing up, with eyes open. Tell patient to close eyes. Wait for 20 to 30 seconds. Then tap the arms briskly downward. When positive, one arm goes downward or drifts

Question 39

Q

Positive Motor Exam

Upper motor neuron diseases = st____, amyotrophic ____ ____, po____

Lower motor neuron lesions = neuro_____, po____ nerve root com____/rad_____) - look for muscle w_____/wa____/at____/fasc_____

Answer

A

Upper motor neuron diseases = (stroke, amyotrophic lateral sclerosis [ALS], polio).

Lower motor neuron lesions = (neuropathy, polio, nerve root compression/radiculopathy) = look for muscle weakness, muscle wasting/atrophy, and fasciculations.

Question 40

Q

Reflex Testing

Both sides should be compared with each other and should be equal.

There are ___ pairs of spinal nerve roots, named for their associated vertebral body. Each pair of nerve roots exits at the corresponding level, innervating distinct ______ distributions

Answer

A

There are 31 pairs of spinal nerve roots, named for their associated vertebral body. Each pair of nerve roots exits at the corresponding level, innervating distinct dermatomal distributions

Question 41

Q

Grading Reflexes

0

1+

2+

3+

4+

Answer

A

0 No response

1+ Low response

2+ Normal or average response

3+ Brisker than average response

4+ Very brisk response (sustained clonus)

Question 42

Q

Deep Tendon Reflexes

Question 43

Q

Quadriceps reflex (knee-jerk response)

Reflex center at ___ to ___

Tap _____ tendon br____ on each side.

Answer

A

Reflex center at L2 to L4.

Tap patellar tendon briskly on each side.

Question 44

Q

Achilles reflex (ankle-jerk response):

Reflex center at ___ to ___ (tibial nerve).

With patient’s legs _____ off the exam table, hold the foot in slight ____flexion and briskly tap the ______ tendon.

Weak to no response with peripheral _____(diabetes, ___ deficiency anemia).

Answer

A

Reflex center at L5 to S2 (tibial nerve).

With patient’s legs dangling off the exam table, hold the foot in slight dorsiflexion and briskly tap the Achilles tendon.

Weak to no response with peripheral neuropathy (diabetes, B12 deficiency anemia).

Question 45

Q

Plantar reflex (Babinski’s sign):

Reflex center __ to __.

St_____ plantar surface of foot on the _____ border from h____ toward the ____ toe (plantar ______ is normal response). Babinski’s sign is positive if toes spread like a ____.

Positive: _____ should have a negative Babinski’s sign. For ______, Babinski’s sign is considered normal finding.

Answer

A

Reflex center L4 to S2.

Stroke plantar surface of foot on the lateral border from heel toward the big toe (plantar flexion is normal response). Babinski’s sign is positive if toes spread like a fan.

Positive: Adults should have a negative Babinski’s sign. For young infants, Babinski’s sign is considered normal finding.

Question 46

Q

Neurologic Maneuvers

(3)

These tests are used to assess for ______ irritation. All are done with the patient in a supine position. In general, these are more sensitive tests in children compared with adults.

Answer

A

Kernig’s Sign

Brudzinski’s Sign

Nuchal Rigidity

These tests are used to assess for meningeal irritation (meningismus). All are done with the patient in a supine position. In general, these are more sensitive tests in children compared with adults.

Question 47

Q

Kernig’s Sign

=

Positive Result =

Answer

A

Flex patient’s hips one at a time, then attempt to straighten the leg while keeping the hip flexed at 90 degrees.

Positive: There is resistance to leg straightening because of painful hamstrings (due to inflammation on lumbar nerve roots) and/or complaints of back pain.

Question 48

Q

Brudzinski’s Sign

=

Positive Result =

Answer

A

Passively flex/bend the patient’s neck toward the chest

Positive: Patient reflexively flexes the hips and knee to relieve pressure and pain (due to inflammation of lumbar nerve roots).

Question 49

Q

Nuchal Rigidity

=

Positive Result =

Answer

A

Tell patient to touch chest with the chin.

Inability to touch the chest secondary to pain is a positive finding.

Question 50

Q

Acute Mild Traumatic Brain Injury in Adults (Concussion)

Mild TBI is defined as a Glasgow Coma Scale score of ___-___ (measured 30 minutes after injury).

> Male or Female?
Early symptoms of acute mild traumatic brain injury (TBI; concussion) includes con______, head____, di_____ or v____, poor b____, and n____ and v____.
Do they usually lose consciousness?
Do they usually get amnesia?

Answer

A

Mild TBI is defined as a Glasgow Coma Scale score of 13 to 15 (measured 30 minutes after injury).

Males (2:1)
Early symptoms of acute mild traumatic brain injury (TBI; concussion) includes confusion, headache, dizziness or vertigo, poor balance, and nausea and vomiting.
Most do not lose consciousness.
Antegrade and retrograde amnesia are common after the injury.

Question 51

Q

Acute Mild Traumatic Brain Injury in Adults (Concussion)

Most Common Cause (1)

(1) accidents (20%–45%)
F____(30%–38%)
___upational accidents (10%)
_____tional accidents (10%),
Ass____ (5%–17%).
Sports with the highest rates of TBI include American ____, ice ____, s____, b____, and r____.
Mild TBI is a common ____-time injury for soldiers who participated in combat

Answer

A

Acceleration/Deceleration forces on the brain tissue.

motor vehicle accidents (20%–45%)
falls (30%–38%)
occupational accidents (10%)
recreational accidents (10%),
assaults (5%–17%).
Sports with the highest rates of TBI include American football, ice hockey, soccer, boxing, and rugby.
Mild TBI is a common war-time injury for soldiers who participated in combat

Question 52

Q

Mild TBI Concussion Assessment

Ask patient about d____ of the accident, such as events leading up to the injury, during the episode, and events that followed after the concussion.

Check _____ history, inquire if on anti_____, chronic acetylsalicylic acid (1) therapy, or nonsteroidal anti-inflammatory drugs (N____) higher risk of brain hemorrhage).

Answer

A

Ask patient about details of the accident, such as events leading up to the injury, during the episode, and events that followed after the concussion.

Check medication history, inquire if on anticoagulation, chronic acetylsalicylic acid (ASA) therapy, or nonsteroidal anti-inflammatory drugs (NSAIDS; higher risk of brain hemorrhage).

Question 53

Q

Mild TBI (Concussion) Eval

Evaluate _____ status, including short-term _____ and att______ span.

Perform a neurologic assessment and CN examination; pay attention to the vision (CN (1)), pupil exam, extraocular movements (CN (3)), facial movements (CN (1)).

Refer patient to the ED if suspected head ____; needs a ___ scan of head (without contrast).

Answer

A

Evaluate mental status, including short-term memory and attention span.

Perform a neurologic assessment and CN examination; pay attention to the vision (CN II), pupil exam, extraocular movements (CN II, IV, VI), facial movements (CN VII).

Refer patient to the ED if suspected head trauma; needs a CT scan of head (without contrast).

Question 54

Q

Mild TBI (Concussion) I

Indications for Hospital Admission

Glasgow Coma Scale score

S______ or other neurologic deficit(s)

Recurrent ______

Abnormal head ___(e.g., midline ____, hem_____, is____, m____ effect)

Answer

A

Glasgow Coma Scale score <15

Seizures or other neurologic deficit(s)

Recurrent vomiting

Abnormal head CT (e.g., midline shift, hemorrhage, ischemia, mass effect)

Question 55

Q

(1)

Autoimmune disease in which antibodies attack the myelin sheath, leading to demyelination

Peak age ___ to ___
More common in (1) gender (2–3:1) and (1) race
Multiple sclerosis (MS) tends to affect the optic nerves (CN __ ), spinal ___, brain____, cer_____, and ____matter.
4subtypes
- (1) (90% of cases)
- (1) (10%),
- (1)
- (1) (about 60% develop MS).

Answer

A

Multiple Sclerosis

Peak age 15 to 45yo
More common in women (2–3:1) and Caucasians.
Multiple sclerosis (MS) tends to affect the optic nerves (CN II), spinal cord, brainstem, cerebellum, and white matter.
4 subtypes
- Relapsing-remitting MS (90% of cases)
- primary progressive MS (10%),
- secondary progressive MS, and
- clinically isolated syndrome (about 60% develop MS).

Question 56

Q

Classic Case of Multiple Sclerosis

Adolescent to adult (1) gender complains of episodes of v____ loss, _____ (double vision), nystagmus, ver_____, problems with b____ and w_____, foot d____, and numbness and par_____ on one side of the f____. Bowel dysfunction (50%) and/or urinary _______ (75%). Reports that when bending neck forward/flexion, an electric shock–like sensation runs down the back (1 sign).

Answer

A

Adolescent to adult female complains of episodes of visual loss, diplopia (double vision), nystagmus, vertigo, problems with balance and walking, foot drop, and numbness and paresthesias on one side of the face. Bowel dysfunction (50%) and/or urinary incontinence (75%). Reports that when bending neck forward/flexion, an electric shock–like sensation runs down the back (Lhermitte sign).

Question 57

Q

Diagnostic Test for MS

=

Treatment

=

Answer

A

MRI of brain and spinal cord

Refer to neurologist for management

Question 58

Q

(1)

A serious acute bacterial infection of the leptomeninges that cover the brain and spinal cord.

Most common pathogens in adults (3)

Is a _____disease (local health department).

Answer

A

Acute Bacterial Meningitis In Adults

A serious acute bacterial infection of the leptomeninges that cover the brain and spinal cord.

S. pneumoniae,N. meningitides, and Haemophilus influenzae (the latter two are gram negative).

Is a reportable disease (local health department)

Question 59

Q

Classic Case of Acute Bacterial Meningitis in Adults

Acute onset of high ___, severe _____, ___neck (nuchal rigidity), and rapid changes in ____ status and LOC. Up to 78% of patients have mental status changes (con____, leth____, stupor). Other symptoms include _____phobia and nausea/vomiting. Some patients may not present with all three symptoms (triad of fever, nuchal rigidity, and change in LOC); suspect _____ epidural abscess.

Answer

A

Acute onset of high fever, severe headache, stiff neck (nuchal rigidity), and rapid changes in mental status and LOC. Up to 78% of patients have mental status changes (confusion, lethargy, stupor). Other symptoms include photophobia and nausea/vomiting. Some patients may not present with all three symptoms (triad of fever, nuchal rigidity, and change in LOC); suspect spinal epidural abscess.

Question 60

Q

Meningitis Diagnostic Imaging

(2)

Which one should be done first if risk of cerebral herniation?

Answer

A

CT head

Lumbar Puncture

CT scan of head before lumbar puncture if risk for cerebral herniation

Question 61

Q

Risk Factors Cerebral Herniation in Meningitis

Pap_______
F____ neurologic deficit
Abnormal L _ _
New-onset s_____ (within 1 week of presentation)
History of central nervous system (CNS) disease (st____, m____)
________ (HIV, immunosuppressive therapy, solid organ or bone marrow transplant).

Answer

A

Papilledema
Focal neurologic deficit
Abnormal LOC
New-onset seizure (within 1 week of presentation)
History of central nervous system (CNS) disease (stroke, mass)
Immunocompromised (HIV, immunosuppressive therapy, solid organ or bone marrow transplant).

Question 62

Q

Lumbar Puncture

(elevated opening pressure)

Cerebrospinal fluid (CSF) = will have large number of (1) cells and appear (1)
How do you make a definitive diagnosis of meningitis? with presence of elevated _____ and low _____ levels in the CSF

Answer

A

Cerebrospinal fluid (CSF) contains large numbers of white blood cells (WBCs; CSF cloudy).
Definitive diagnosis made from bacteria isolated from the CSF, with presence of elevated protein and low glucose levels in the CSF.

Question 63

Q

Bacterial Meningitis Lab Tests

(4)

Gram stain and culture and sensitivity (C&S) of (2) are needed (before antibiotics are begun).

What if the imaging studies from the LP are delayed?

Answer

A

CBC with differentia and platelet count, metabolic panel, coagulation profile, and blood cultures × 2.

Gram stain and culture and sensitivity (C&S) of CSF fluid and blood are needed (before antibiotics are begun)

Do not delay antimicrobial therapy if LP delayed by imaging studies. Obtain blood cultures and start empiric antibiotics as soon as possible.

Question 64

Q

Bacterial Meningitis Treatment*

Adults:* (1) + (1)
Older than age 50:* (1) + (1)

Prophylaxis of close contacts with (1) PO or (1) IM

(1) Vaccination shown to decrease incidence

Answer

A

Adults:* Third-generation cephalosporin IV plus chloramphenicol IV
Older than age 50:* Amoxicillin IV plus third-generation cephalosporin IV

Prophylaxis of close contacts with rifampin PO or ceftriaxone IM

Pneumococcal vaccination shown to decrease incidence

Answer 64

A

Patients who recover usually have permanent neurologic sequelae.

Older patients have a higher mortality rate due to the presence of comorbid conditions.

Answer 65

A

Migraine without aura

At risk patients = Adult females

Aggravating Factors = Red wine, MSG, Aspartame, Menstruation, Stress

Answer 66

A

Migraine With Aura

At risk patients = Adult females

Aggravating factors = Foods high in tyrosine

Answer 67

A

Trigeminal Neuralgia (CN V)

At Risk Patients = Older adults and Elderly

Aggravating Factors = Cold food, cold air, talking, touching, chewing

Answer 68

A

Cluster Headaches

At risk patients = Middle-aged males

Aggravating factors = Occurs at same time daily in clusters for weeks to months

Answer 69

A

Giant cell arteritis (temporal arteritis)

At risk patients = Older patients and elderly

Aggravating Factors = Medical emergency; can cause blindness if not treated, Polymyalgia rheumatic common in these patients

Answer 70

A

Muscle Tension Headaches

At risk patients = Adults

Aggravating Factors = Stress

Answer 71

A

Migraine headache with aura (precedes onset of migraine headache) may present as scotomas (blind spots on visual field) or flashing lights that precede the headache.

Females with a positive family history are at higher risk (3:1).

In children, migraine headaches can present as abdominal pain.

Answer 72

A

An adult woman complains of the gradual onset of a throbbing headache behind one eye that gradually worsens over several hours. Reports sensitivity to bright light (photophobia) and noise (phonophobia). Frequently accompanied by nausea and/or vomiting, which can be severe. Migraines can last from 3 to 72 hours and may become bilateral if not treated.

Answer 73

A

Neurologic exam will be normal.

Rest in a quiet and darkened room with an ice pack to forehead.

Nausea: Drink ginger ale or cola; chew dry toast or saltine crackers.

Avoid heavy, fatty meals.

Avoid precipitating foods or activities:

Monosodium glutamate (MSG) in Chinese food; chocolate; nitrates/nitrites found in hot dogs, luncheon meat, and sausage
Red wine, beer, caffeine
Sleep changes, stress, barometric weather changes

Answer 74

A

Odor trigger such as tobacco smoke, perfumes, and strong odors

Visual triggers such as strobe lights, sunlight, glares

Emotional or psychical stress

Answer 75

A

First, rule out cardiovascular disease.

Do not use (or mix) triptans or ergots if history or signs of ischemic heart disease (myocardial infarction [MI], angina), cerebrovascular accident (CVA), transient ischemic attacks (TIAs), uncontrolled hypertension, or hemiplegic migraine.
Warn patient of possible flushing, tingling, chest/neck/sinus/jaw discomfort.
Supervise first dose, especially if patient has risk factors for cardiovascular disease (e.g., diabetics, obese, males >40 years, high lipids). Give first dose in office (theoretical risk of an acute MI).

Answer 76

A

Consider EKG monitoring if patient is at high risk for heart disease.

Higher risk of serotonin syndrome if combined with selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs; duloxetine [Cymbalta], venlafaxine [Effexor]). Do not combine or start within 2 weeks of monoamine oxidase inhibitor (MAOI) use.

Do not combine with ergots or within 24 hours of ergot use (e.g., ergotamine/caffeine or Cafergot).

Answer 77

A

Analgesics +/-, NSAIDS

Analgesics ie Extra Strength Tylenol

If migraine headache with nausea or vomiting, also prescribe oral or rectal antiemetic drug.
Educate patient that it is best to take pain medication as soon as pain starts, rather than waiting until it is severe.

Answer 78

A

Oral triptans or combination sumatriptan–NSAID/naproxen (Treximet).

If associated with severe nausea or vomiting, use non-oral agents such as subcutaneous sumatriptan (Imitrix), nasal sumatriptan, and zolmitriptan (Zomig) with antiemetic drug.

Answer 79

A

Calcitonin gene-related peptide (CGRP) antagonists**:

Rimegepant (Nurtec)

Ubrogepant (Ubrelvy)

Erenumab (Aimovig)

fremanezumab- (Ajovy)

galcanezumab-gnlm (Emgality)

Answer 80

A

ketoconazole, itraconazole, clarithromycin

Grapefruit juice, St. John’s wort.

Has numerous major drug interactions.

Answer 81

A

Erenumab (Aimovig) is used to prevent (prophylaxis) both episodic and chronic migraine headaches in adults. It is made up of monoclonal antibodies. Autoinjector pen is used once a month at home.

Serotonin 5-HT-1F receptor agonist: Lasmiditan (Reyvow)

– Do not use within 8 hours of driving or operating heavy machinery (causes dizziness).

Answer 82

A

Ergot alkaloids are potent vasoconstrictors.

Do not mix with other vasoconstrictors (e.g., triptans, decongestants).

Common side effect is nausea.

Ergots and triptans should not be given within 14 days of an MAOI.

Answer 83

A

Prochlorperazine*: Intramuscular (IM), intravenous (IV), suppository, by mouth (PO).
Trimethobenzamide (Tigan)*: IM, suppository, PO.
Ondansetron (Zofran*): IM, IV, PO. Off-label use for acute severe nausea and/or vomiting.

Answer 84

A

Beta-blockers*
Tricyclic antidepressants (TCAs)*
Selective norepinephrine reuptake inhibitor (SNRIs)*
Anticonvulsants*

Answer 85

A

Beta-blockers:* Propranolol (Inderal) daily or twice a day (other beta-blockers can also be used)
Tricyclic antidepressants (TCAs):* Amitriptyline (Elavil) at bedtime (HS)
Other TCAs:* Desipramine (Norpramin), imipramine (Tofranil), nortriptyline (Pamelor)
Selective norepinephrine reuptake inhibitor:* Venlafaxine (Effexor)
Other drug classes:* Anticonvulsants (valproate, topiramate)

Answer 86

A

(Vasoconstricting Drugs)

Suspected or known cardiovascular disease (angina, MI, peripheral arterial disease)

Suspected or known CVA and/or TIAs

Hyperlipidemia, males older than 40 years of age, menopausal females

Uncontrolled hypertension

Complex migraine (i.e., basilar/hemiplegic migraine)

Answer 87

A

Distinguish the drugs used for abortive treatment versus chronic prophylaxis.

Answer options may list the drug class instead of the generic name.

Answer 88

A

Migraine with Brainstem Aura (Basilar or Hemiplegic Migraines)

Stroke symptoms without one sided body weakness (hemiplegia)

Answer 89

A

A systemic inflammatory disorder of the medium and large arteries (vasculitis) of the body.

Acute onset of a unilateral headache that is located on the temple and associated with temporal artery inflammation.
Visual loss is not uncommon and occurs in 15% to 20% of patients (despite availability of steroids).
Peak incidence is between ages 70 and 79 years.

Answer 90

A

An older man complains of headache on his temple along with marked scalp tenderness on the same side. Presence of an indurated cord-like temporal artery that is warm and tender. Sometimes accompanied by jaw claudication (pain with chewing that is relieved when he stops chewing).

Complains of visual symptoms such as amaurosis fugax (transient monocular loss of vision or partial visual field defect) or blindness. Can be accompanied by systemic symptoms such as low-grade fever and fatigue. Sedimentation rate is markedly elevated

Answer 91

A

Elevated ESR and CRP

ESR Normal range
- Men = 0 and 22 mm/hour
- Women = 0 and 29 mm/hour
ESR/sedimentation rate in Giant Cell Arteritis (often reaches 100 mm/hour or more).

Answer 92

A

Temporal artery biopsy by ophthalmologist or surgeon

Refer to ophthalmologist, rheumatologist, or ED stat.

High-dose steroids are part of first-line treatment (prednisone 40–60 mg by mouth daily).

Answer 93

A

Permanent blindness may occur if not diagnosed early (ischemic optic neuropathy).

Answer 94

A

Temporal arteritis is treated with high-dose prednisone for several weeks. Refer to rheumatology specialist for management.

Sedimentation rate is a screening test for temporal arteritis (elevated).

Answer 95

A

Because temporal arteritis can cause blindness, regard with high index of suspicion. If history and physical exam are suggestive, treat with oral steroids as soon as possible, or refer to ED.

For temporal arteritis, order sedimentation rate and CRP. Both will be elevated.

Serial labs (ESR, CRP) should be ordered until symptoms improve and should be monitored frequently.

Answer 96

A

PMR is an inflammatory condition seen almost exclusively in people age 50 or older. Peak incidence is between ages 70 and 79 years. It is more common in females. The cause is unknown.

The ESR is elevated mildly to severely (20% sedimentation rate 104 mm/hour); CRP is also elevated.
PMR patients are at very high risk (up to 40%–50%) of developing temporal arteritis. Educate patients diagnosed with PMR on how to recognize symptoms of temporal arteritis.

Answer 97

A

Bilateral joint stiffness and aching

(lasting 30 minutes or longer, commonly in the morning hours) located in the posterior neck, shoulders, upper arms, and hips (pelvic girdle).

Pelvic girdle symptoms

include groin pain and pain at lateral aspects of the hips, which may radiate to the posterior thigh area. Has difficulty putting on clothes, hooking bra in the back, or getting up out of bed or a chair.

Gel Phenomenon - Severe morning stiffness and pain

can last until the afternoon if not treated with steroids. Symptoms usually respond quickly to oral steroids (e.g., prednisone daily).

Answer 98

A

The trigeminal nerve (CN V) has three divisions: the ophthalmic (V1), maxillary (V2), and mandibular (V3) branches.

Most cases are caused by compression of the nerve root by an artery, vein, or tumor, causing a unilateral facial pain that follows one of the branches of the trigeminal nerve.

The pain is usually located close to the nasal border and cheeks, but it can move to other areas of the face.

There are three types: classic, secondary (underlying disease), and idiopathic. More common in women and peaks in the 60s.

Answer 99

A

An older adult complains of the sudden onset of severe and sharp shooting pains on one side of her face or around the nose that are triggered by chewing, eating cold foods, and cold air.

The severe lacerating pain (piercing knifelike pain) lasts a few seconds to 2 minutes. Pain is precipitated by a stimulus on any area of the trigeminal nerve. The patient may stop chewing or speaking momentarily (few seconds) if it causes the pain. Has recurrent paroxysms of unilateral facial pain that follows the distribution of the trigeminal nerve (CN V).

Answer 100

A

High doses of Anticonvulsants such as Carbamazepine (Tegretol).

Muscle Relaxants (Baclofen, Robaxin, Norflex, or Flexeril) effective when used with anticonvulsant

Oxcarbazepine (Trileptal) most recently used as first-line drug with fewer side effects.
Gabapentin and topiramate also used effectively.

Topical lidocaine intraoral application to reduce pain if severe in mouth

Answer 101

A

MRI or CT To rule out tumor/artery pressing on nerve or MS

Craniotomy for microvascular decompression referral If MRI detects lesion or arterial/venous compression

Surgical therapy (rhizotomy, radiofrequency, nerve block) for refractory cases

Answer 102

A

Bell’s Palsy

Herpesvirus activation is suspected to be the most likely cause of majority of cases.

Facial paralysis can progress rapidly within 24 hours.
Skin sensation remains intact, but tear production on the affected side may stop.
Most cases resolve spontaneously.

Answer 103

A

An older adult reports waking up that morning with one side of his face paralyzed. Complains of difficulty chewing and swallowing food on the same side. Unable to fully close eyelid on affected side.

Answer 104

A

High Dose Glucocorticoid + Valacyclovir/Acyclovir

Early treatment with high-dose oral glucocorticoids (60–80 mg/day) × 7 days and wean plus

valacyclovir (1,000 mg three times a day) or acyclovir (400 mg five times daily) × 7 days.

Best if treatment started as soon as possible, within 3 days of onset.

Answer 105

A

Artificial tears (liquid, gel) every hour while patient is awake to protect cornea from drying and ulceration

Use protective glasses or goggles.

At night, use ointment (containing mineral oil and white petrolatum) and cover with eye patch.

Answer 106

A

Corneal Ulceration

Prolonged cases (several weeks) may leave permanent neurologic sequelae, such as permanent facial weakness, in up to 10% of patients.

Recurrent attacks happen in 7% to 14% of cases.

Answer 107

A

Cluster Headache

Answer 108

A

Abrupt onset; may get agitated during a headache episode.

The attacks happen several times a day (cluster).

Individual attack last from 15 minutes to 3 hours.

Resolves spontaneously but may return in the future in some patients.

More common in adult males in their 30s to 40s.

Increased risk of suicide if it persists (due to severe intensity of pain).

Answer 109

A

A 35-year-old man complains of the abrupt onset of recurrent episodes of brief “ice-pick” (lacerating pain) headaches behind one eye, above the eye/brow area or temporal area, that are accompanied by autonomic symptoms such as tearing and clear nasal discharge (rhinitis). Some may have drooping eyelid (ptosis). May be pacing the floor during an acute attack.

Answer 110

A

High-dose Oxygen at least 12L/min by mask*

Continue oxygen treatment for 15 minutes. Do not use high-dose oxygen if patient has chronic obstructive pulmonary disease (COPD).

Sumatriptan (Imitrex) 6 mg

subcutaneous injection or intranasal route as initial therapy or combination with high-dose oxygen.

Melatonin

10 mg immediate-release tablet taken in the late evening (found to reduce headache frequency).

Capsaicin

0.025% smear on ipsilateral nostril × 7 days may help.

Answer 111

A

CCB verapamil

by mouth daily if chronic

If dose >400 mg EKG monitoring due to risk of bradycardia, right bundle branch block (RBBB), or complete heart block.

Avoid grapefruit juice.

Answer 112

A

Suicide

Higher risk of suicide (males) compared with the other types of chronic headaches.

Answer 113

A

Tension Headache

Answer 114

A

An adult patient complains of a headache that is “band-like” and feels like “someone is squeezing my head.” The pain is described as dull and constant. Often accompanied by tensing of the neck muscles. The headache may last several days. Patient reports recent increased life stressor(s).

Answer 115

A

NSAIDs first line

Naproxen sodium BID, Ibuprofen QID, or Aspirin every 4 to 6 hours.
Acetaminophen is an option if unable to tolerate NSAIDs (preferred option during pregnancy)
Diclofenac TID if poor response to NSAIDs

Combination drugs such as ibuprofen or aspirin with caffeine

For patients who do not get satisfactory pain relief from single agent

Answer 116

A

Limit butalbital use to three times or less per month.

Current guidelines do not recommend the use of opioids or butalbital as initial therapy for tension-type headache (TTH).

Muscle relaxants are not recommended; they can be addicting for some patients.

Answer 117

A

Stress reduction and relaxation

Try yoga, tai chi; exercise several times per week; gradually reduce and stop caffeine intake; follow a regular eating/sleep schedule; pursue counseling with therapist.

Answer 118

A

Defined as headache occurring 15 or more days per month due to overuse of acute headache medications for >3 months.

Caused by overuse of abortive medicines such as analgesics, NSAIDs, aspirin, combination NSAID or acetaminophen with caffeine, butalbital, barbiturates, ergots, triptans, or opioids.

More common in women.
Patients with migraine who are depressed or anxious may be at risk.
Patient complains of daily headaches (or almost daily headaches). May be accompanied by irritability, depression, and insomnia.

Answer 119

A

(OTC) analgesics or triptans limit to ≤9 days a month.
NSAIDs, limit use to ≤15 days per month.
Butalbital, limit to ≤3 days per month.

Treatment is to discontinue the medicine immediately (if not contraindicated) or gradually taper the dose and/or reduce frequency.

Answer 120

A

Transient Ischemic Attack

high risk for a subsequent stroke and needs urgent evaluation and treatment.
The timing for resolution (24 hours, included in previous definition) has been removed.
It is now known that permanent neurologic damage can occur with TIAs (as seen in CVAs or strokes). TIA is also known as a “ministroke” or “minor stroke.”

Depending on severity of the TIA, the signs and symptoms can be subtle to severe. The longer the episode of the TIA, the higher the risk of ischemic brain damage. The TIA can progress into a full-blown stroke. Signs and symptoms of CVA or stroke can be insidious and start a few days before the major episode occurs.

Answer 121

A

ABCD2 score

Age, Blood pressure, Clinical features, Duration of symptoms, and Diabetes

Predicts who is at high risk for suffering a subsequent stroke after a TIA within the next 7 days

Score of ≥3 = refer to ED

Answer 122

A

A TIA is a major warning sign; 15% of patients with stroke report a previous TIA. The major risk factor for stroke is hypertension.

Answer 123

A

Adult to elderly patient reports acute onset of one-sided weakness of the right arm and right leg accompanied by dizziness, vertigo, and poor balance. The patient is difficult to understand because his speech is slurred (dysphasia). When instructed to smile and grimace, the right side of his face has no movement and is lopsided. Patient is accompanied by a spouse who reports that he has a history of hypertension, atrial fibrillation, hyperlipidemia, and type 2 diabetes. If symptoms progress to stroke, one-sided weakness worsens, and LOC ranges from confusion and stupor, to coma. If a TIA episode, the signs and symptoms eventually resolve, but patient remains at higher risk of future stroke.

Answer 124

A

Age ≥60 years

History of TIA or ischemic stroke within 30 days of index event

History of diabetes

Systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg

Unilateral weakness

Isolated speech disturbance

TIA duration >10 minutes

Answer 125

A

F Face drooping (Instruct patient to smile. Is face lopsided?)

A Arm weakness (Instruct patient to raise both arms. Does one arm drift downward?)

S Speech difficulty (Instruct patient to say, “The sky is blue.”)

T Time to call 911 (Even if symptoms go away, call 911.)

Answer 126

A

Consider hospitalization within first 24 to 48 hours if (high risk of early stroke):

Presence of known cardiac, arterial, or systemic etiology of brain ischemia that is amenable to treatment

ABCD2 questionnaire score of ≥3

Patient’s first TIA or duration of TIA is ≥1 hour

High risk for cardiac emboli (e.g., atrial fibrillation)

Symptomatic internal carotid stenosis >50%

Hypercoagulable state

Crescendo TIAs (two or more TIAs in 1 week)

Answer 127

A

Refer patient to ED for further evaluation. Find out cause of TIA (or stroke), such as atrial fibrillation, carotid/vertebral atherosclerosis, hypercoagulable state, cocaine use, hypertension. Perform workup to find the extent of brain damage.

Schedule CT and/or MRI scan as soon as possible (within first 24 hours of the episode). Diffusion-weighted MRI is the preferred imaging method.

Rule out intracranial hemorrhage before starting aspirin (50–325 mg/day), plus extended-release dipyridamole or clopidogrel.

Maintain BP <140/90 mmHg.

Answer 128

A

Emboli (local obstruction of an artery),
Thrombosis (debris originating elsewhere that blocks an artery),
Hemorrhage -(2 types)
1. Intracerebral (bleed directly into the brain)
2. Subarachnoid (bleeding into subarachnoid space and CSF).

The obstruction or bleeding causes permanent damage to the brain

Answer 129

A

Atrial Fibrillation and Hypertension.

Aneurysms, trauma, bleeding abnormalities, and use of anticoagulants (e.g., warfarin [Coumadin])
Use of stimulants (cocaine/illicit drugs), sickle cell disease, diabetes, oral contraceptive use, smoking, and thrombophilia.
Blacks, Hispanics, and American Indians/Alaskan Natives have a higher prevalence of stroke.
An ischemic stroke is due to emboli that broke off from thrombus formation in the body; common locations are the lower extremities and the heart (atrial fibrillation).

Answer 130

A

A patient with embolic stroke presents with the abrupt onset of difficulty speaking, unilateral hemiparesis, and weakness of the arms or legs (or both).

Patients with hemorrhagic stroke often initially present with severe headache, nausea/vomiting, photophobia, and nuchal rigidity that is accompanied by hemiparesis and difficulty speaking.

Answer 131

A

Subarachnoid hemorrhage SAH or intracerebral hemorrhage (ICH):

Sudden onset of severe “thunderclap” headache that is described as “the worst headache of my life.” The pain from the headache may radiate to the neck or back. Rapid decrease in LOC (coma, death). SAH usually begins abruptly compared with more gradual ICH.

Answer 132

A

Vomiting is more common in hemorrhagic strokes (compared with embolic strokes). Usually caused by a ruptured aneurysm or vascular malformations.

“Sentinel headache” may be seen in SAH. About 30% of patients have minor hemorrhagic episodes that present with sudden severe headache as the only symptom.

Answer 133

A

Signs and symptoms are dependent on artery involved. Middle cerebral artery is the largest cerebral artery, and it is the most commonly affected by stroke. For example:

Left middle cerebral artery occlusion of the superior branch: Right side of face, right arm, right leg weakness, hemianopia, with expressive aphasia (Broca’s area)
Right middle cerebral artery: Left side of face, left arm, left leg with hemineglect and possible hemianopia

Answer 134

A

Call 911.

Assess the ABCs as soon as possible; check for airway patency, chest movement, breath sounds from both lungs, and circulation.

Check vital signs and neuro status.

Answer 135

A

Assess the ABCs and stabilize patient.

Initial imaging study in the ED is CT scan (without contrast) and then an MRI study.

Time is critical; do not delay antithrombolytic therapy, and check blood glucose (must be <180 mg).

According to 2019 American Heart Association (AHA) Stroke Guidelines, alteplase can be given up to 4.5 hours from start of symptoms.

Answer 136

A

Homonymous hemianopia:* Visual field loss involving either the two left halves (or the two right halves) of the visual field. Most common cause is stroke. There are many types of hemianopia.
Perform screening test:* Visual fields by confrontation.

Answer 137

A

Left sided Homonymous Hemianopia = Left side is blind

The diagram at right shows the intact and missing visual fields of a person who has left-sided homonymous hemianopia. The “x” signifies the missing visual fields, and the “==” are the intact visual field.

Answer 138

A

Damage to Temporal Lobe

Apraxia: Patient has difficulty performing purposeful movements.

Broca’s aphasia: Also known as “expressive aphasia.” Patient comprehends speech relatively well (and can read) but has extreme difficulty with the motor aspects of speech. Speech length is usually less than four words.

Wernicke’s aphasia: Also known as “receptive aphasia.” Patient has difficulty with comprehension but has no problem with producing speech. Reading and writing can be markedly impaired.

Answer 139

A

Frontal lobe damage:

Affects intelligence, executive skills, logic, and personality reside. Damage will cause dementia, memory loss/difficulties, inability to learn.

Answer 140

A

Treatment includes BP reduction, statins, antiplatelets, anticoagulants, and carotid revascularization. Lifestyle and dietary changes help to reduce risk of stroke.

Remove or treat the cause of the emboli (e.g., atrial fibrillation; control hypertension).

Rehabilitation: Physical therapy, occupational therapy, speech therapy.

Patient should be in the care of a neurologist.

Answer 141

A

For embolic strokes:* Anticoagulation therapy; statin therapy; keep international normalized ratio (INR) between 2.0 and 3.0.
For hemorrhagic strokes:* Avoid heparin, warfarin, aspirin, NSAIDs.

Answer 142

A

Naproxen sodium (Naprosyn, Aleve) BID or ibuprofen (Advil, Motrin) TID to QID

Side effects: GI pain/bleeding/ulceration, renal damage, increased BP in hypertension

Answer 143

A

sumatriptan succinate (Imitrex)

injection, inhalant, PO tablets, or sublingual tablets. For acute pain, give injection subcutaneously (onset 10 minutes).

Side effects: Nausea; dizziness; vertigo; drowsiness; discomfort of throat, nose, and/or tongue.

Answer 144

A

Contraindicated for patients with cardiovascular comorbidities, since it causes vasoconstriction

(coronary artery spasm, MI, transient myocardial ischemia), arrythmias (atrial fibrillation, ventricular fibrillation, ventricular tachycardia).

Triptans should not be given within 24 hours of an ergot.

Do not give within 14 days of an MAOI.

Answer 145

A

ce pack on forehead; rest in quiet and darkened room

Sumatriptan SC injection; use injection or nasal spray formulation triptan if severe nausea

Ketorolac IM with antinausea injection

Prochlorperazine IM for nausea

Answer 146

A

TCAs (Amitriptyline)

Beta-blockers (propranolol, metoprolol, timolol)

Do not use BB if age 60 or smoker/chronic lung disease, do not use it

SNRI (Venlafaxine)

especially if comorbid generalized anxiety disorder, panic disorder

Anticonvulsant (Topiramate, Valproate)

Do not use BB if age 60 or smoker/chronic lung disease, do not use it

Answer 147

A

High-Dose Steroids

Refer to ED or ophthalmologist stat

Screening Lab Test: ESR ↑

Answer 148

A

100% oxygen at 12 L/min; use mask; intranasal 4% lidocaine

Answer 149

A

May become suicidal*

Spontaneous resolution; can recur

Answer 150

A

Anticonvulsants

Carbamazepine (Tegretol) or Phenytoin (Dilantin)

Check Serum levels

Use for several weeks to months; watch for drug interactions

Answer 151

A

NSAIDs, acetaminophen, hot bath/shower, massage

Stress reduction, yoga, biofeedback

Answer 152

A

Acetaminophen (Tylenol) four times a day as needed

Side effects: Hepatic damage

Prophylaxis (must be taken to work daily)

Answer 153

A

Tricyclic Antidepressants

Amitriptyline (Elavil), nortriptyline, doxepin, or imipramine
Side effects: Sedation, dry mouth, confusion in older adults

Beta-Blockers

Propranolol (Inderal LA) or atenolol (Tenormin) daily. Careful with older patients.
Contraindications: Second- or third-degree atrioventricular (AV) block, asthma, COPD, bradycardia

Answer 154

A

Selective Norepinephrine and Serotonin Inhibitors

Venlafaxine (Effexor) daily at bedtime.
Consider if patient has both migraine and depression, generalized anxiety disorder, panic disorder, chronic anxiety.

Antiseizure Medications

Topiramate (Topamax)
If discontinuing drug, withdraw gradually over a few weeks to minimize risk of seizures or withdrawal symptoms

Answer 155

A

Median nerve compression due to swelling of the carpal tunnel.

Commonly caused by activities that require repetitive wrist/hand motion.

Both hands affected in 50% of patients.
More common in women (3:1).
Other factors that increase risk are hypothyroidism, pregnancy, rheumatoid arthritis, and obesity.

Answer 156

A

An adult female patient complains of gradual onset (over weeks to months) of numbness and tingling (paresthesias) on the thumb, index finger, and middle finger areas. Hand grip of affected hand(s) is weaker. May complain of problems lifting heavy objects with the affected hand. Symptoms are worsened by repetitive actions of the hand or wrist and during sleep. Chronic severe cases involve atrophy of the thenar eminence (the group of muscles on the palm of the hand at the base of the thumb), which is a late sign. History of an occupation or hobby that involves frequent wrist/hand movements.

Answer 157

A

Tap anterior wrist briskly

Positive: “Pins and needles” sensation of the median nerve over the hand after lightly percussing the wris

Answer 158

A

Engage in full flexion of wrist for 60 seconds

Positive: Tingling sensation of the median nerve over the hand evoked by passive flexion of the wrist for 1 minute

Answer 159

A

Recognize both Tinel’s and Phalen’s signs (tests for carpal tunnel syndrome [CTS]) or compression of median nerve).

Instead of being called CTS, may be called inflammation of the median nerve.

Alternative headache remedy is an herb called butterbur.

With the exception of muscle tension headaches, which are bilateral, all of the headaches seen on the exam (and notes) are unilateral.

Answer 160

A

Muscle tension:* Causes band-like head pain; may last for days.
Migraines:* Can last from 3 hours to 72 hours.
Cluster:* Only headache accompanied by tearing and nasal congestion; severe pain is behind one eye/one side of head. Occurs several times a day. Spontaneously resolves. Seen more in middle-aged males. Treated with high-dose oxygen (contraindicated in COPD).

Answer 161

A

Trigeminal neuralgia (tic douloureux):* Pain on one side of face/cheek is precipitated by talking, chewing, cold food, or cold air on affected area.
Giant cell arteritis/temporal arteritis:* Indurated temporal artery, pain felt behind eye/scalp. Treated with high-dose steroids or other anti-inflammatory medication. Untreated may lead to blindness.

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Nervous System Flashcards

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