Nervous system

Question 1

Hemorrhagic stroke usually results in…

Answer 1

Abrupt onset of a severe headache, nausea/vomiting, and nuchal rigidity (subarachnoid hemorrhage [SAH]).

Patient may have uncontrolled hypertension.

Question 2

S/S Giant Cell Arteritis

Answer 2

New headache or change in preexisting headache, abrupt visual disturbances or vision loss, jaw claudication, unexplained fever, and signs/symptoms of vascular abnormalities. Burning temporal pain.

Question 3

S/S MS

Answer 3

Episodic visual loss or diplopia (double vision), problems with balance and walking, and numbness and paresthesia 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).

Question 4

S/S subarachnoid hemorrhage

Answer 4

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. 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.

Non contrast CT

Medical emergency

Question 5

Stereognosis

Answer 5

Ability to Recognize Familiar Object Through Sense of Touch Only

Question 6

Graphesthesia

Answer 6

Ability to Identify Figures “Written” on Skin

Question 7

Reflex grading

Answer 7

0 No response

1+ Low response

2+ Normal or average response

3+ Brisker than average response

4+ Very brisk response (sustained clonus)

Question 8

Kernig’s Sign

Answer 8

Flex patient’s hips one at a time, then attempt to straighten the leg while keeping the hip flexed at 90 degrees. Test is positive if there is resistance to leg straightening because of painful hamstrings (due to inflammation on lumbar nerve roots) and/or complaints of back pain.

Question 9

Brudzinski’s Sign

Answer 9

Passively flex/bend the patient’s neck toward the chest (see lesson “Figure 12.5 Brudzinski’s sign test”). Test is positive if patient reflexively flexes the hips and knee to relieve pressure and pain (due to inflammation of lumbar nerve roots).

Question 10

Bacterial meningitis

Answer 10

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

The most common pathogens in adults are Streptococcus pneumoniae, N. meningitidis, and Haemophilus influenzae (the latter two are gram negative).

Bacterial meningitis is a reportable disease (local health department).

Question 11

S/S of acute bacterial meningitis

Answer 11

Acute onset of fever >100.4°F (38°C), severe headache, stiff neck (nuchal rigidity), and rapid changes in mental status and LOC (confusion, lethargy, stupor). Photophobia and nausea/vomiting.

Question 12

Diagnostics for acute bacterial meningitis

Answer 12

• CBC, CMP, coag, blood cultures x2
• CT (if Papilledema, focal neurologic deficit, abnormal LOC, new-onset seizure, hx central nervous system disease (stroke, mass) or immunocompromised
• LP (with gram stain and culture)
• Antibiotics

Question 13

Treatment for bacterial meningitis

Answer 13

cefotaxime or ceftriaxone

PLUS

Vancomycin

PLUS

Ampicillin

Question 14

Bells Palsy

Answer 14

Abrupt onset of unilateral facial paralysis due to dysfunction of the motor branch of the facial nerve (CN VII). 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.

Herpes simplex virus activation is suspected to be the most likely cause in many cases.

Question 15

Treatment for Bells Palsy

Answer 15

Early treatment with high-dose oral glucocorticoids (prednisone 60–80 mg/day) for 1 week.

For patients with severe palsy, coadministration with antiviral therapy is recommended: valacyclovir (1,000 mg three times a day) OR acyclovir (400 mg five times daily) × 7 days.

Eye drops and eye protection.

Question 16

Tinel’s Sign

Answer 16

Identifies compression of the ulnar nerve. With the elbow relaxed and palm up, tap anterior wrist briskly. Positive sign is “pins and needles” sensation of the median nerve over the hand after lightly percussing the wrist.

Question 17

Phalen’s Sign

Answer 17

Engage in full flexion of wrist for 60 seconds (see lesson “Figure 12.7 Phalen’s sign”). Positive sign is numbness or tingling sensation of the median nerve over the hand evoked by passive flexion of the wrist for 1 minute.

Question 18

Apraxia

Answer 18

patient has difficulty performing purposeful movements.

Question 19

Broca’s aphasia

Answer 19

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

Question 20

Wernicke’s aphasia

Answer 20

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

Question 21

Giant cell arteritis

Answer 21

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

ESR and CRP may be elevated

Question 22

Treatment for giant cell arteritis

Answer 22

• refer to opthalmologist/rheumatologist/ED stat
• Temporal artery biopsy
• high dose glucocorticoids (prednisone, methylprednisolone) for weeks
• monitor ESR and CRP for improvement

Question 23

MS

Answer 23

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

Question 24

Diagnostics for MS

Answer 24

• MRI of brain and spinal cord
• refer to neurology for management

Question 25

Polymyalgia rheumatica

Answer 25

Inflammatory disorder that causes pain and stiffness in the muscles around the neck, shoulders, upper arms, and hips. It’s most common in people over 50, especially women, and is more prevalent in Caucasian people.

Elevated ESR, CRP
Higher risk for GCA

Question 26

S/S polymyalgia rheumatica

Answer 26

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. Patient has difficulty putting on clothes, hooking bra in the back, or getting up out of bed or a chair.

Question 27

Cluster headache

Answer 27

Idiopathic and severe one-sided headache that is marked by recurrent episodes of severe and stabbing pain located behind one eye that is accompanied by lacrimation, nasal congestion, and clear rhinitis with conjunctival injection (red eyes), ptosis (drooping eyelid), and miosis (constriction of pupil) on the ipsilateral side (same side as headache)

Question 28

Treatment for cluster headache

Answer 28

MRI to rule out tumor
High flow oxygen
Triptans

Question 29

Cluster headache prophylaxis

Answer 29

verapamil or glucocorticoids for infrequent attacks

Question 30

Migraine headache

Answer 30

a severe headache generally associated with nausea and/or light and sound sensitivity. May be with or without aura.

Answer 31

Mild to moderate - tylenol/ibuprofen/zofran
Moderate to severe - triptans,

prophlactic treatment - beta blockers, CCB, ACE, ARB, TCA, anticonvulsants,

Question 32

Treatment for trigeminal neuralgia

Answer 32

Carbamazepine

Question 33

Pharmacotherapy for seizures

Answer 33

Carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, phenobarbital, phenytoin, topiramate, valproate

Question 34

TIA treament

Answer 34

1. Refer to ED or specialty clinic - get head CT to determine the cause
2. start antiplatelet therapy
3. CBC, coagulation panel, serum electrolytes and creatinine, fasting blood glucose, lipid panel, hemoglobin A1C, ESR, and CRP
4. EKG
5. maintain BP <140/90

Question 35

Trigeminal neuralgia

Answer 35

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

Trigeminal neuralgia (tic douloureux) is pain on one side of face/cheek, precipitated by talking, chewing, cold food, or cold air on affected area.

Question 36

Embolic strokes often arise from a source in the …

Answer 36

heart, aorta, or large vessels

Question 37

Risk factors for stroke after TIA

Answer 37

60 years or older; history of TIA or ischemic stroke within 30 days of index event (1.5%–3.5% in the first 48 hours); history of diabetes; systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg; unilateral weakness; isolated speech disturbance; TIA duration greater than 10 minutes; presence of vascular pathologies (e.g., large artery atherosclerosis, small vessel disease); and presence of acute infarction on MRI or acute or chronic ischemic lesions on CT.