Neuro Flashcards
What is the red flags in headache
SNOOP
S- systemic symptoms
N- neurological symptoms
O-onset new or changed, >50 year
O-onset thunderclap
P-position changes
GCA s/s
Jaw clarification
Headache
Abrupt visual disturbances
Unexplained fever
Affected temple has an infuriated reddened and cord like temporal artery with scalp tenderness
A patient presents with acute right-sided weakness, aphasia, and a facial droop. Based on this clinical presentation, which of the following diagnostic tests is the priority to obtain first to guide further treatment decisions?
A. MRI brain without contrast
B. CT angiography
C. MRI brain with contrast
D. CT head without contrast
Answer: D. CT head without contrast
Non-contrast head CT is the preferred imaging study for early and initial acute stroke evaluation due to its availability, rapid scan times, and sensitivity for intracranial hemorrhage or mass lesion. An initial non-contrast CT scan can confirm the ability to proceed with administration of tissue plasminogen activator, if indicated. Further work-up, including CT angiography or MRI, may be subsequently performed, but a non-contrast head CT is the priority due to its speed of acquisition and increased access. MRI reliably detects intracranial hemorrhage and is superior for the detection of acute ischemic stroke, but it is not as readily available and is more limited by patient contraindications or intolerance. A CT angiography is often performed during further evaluation to detect intracranial large vessel stenosis and occlusions.
Which of the following is a contraindication for prescribing the “triptan” drug class?
A.Peptic ulcer disease
B.Ischemic heart disease
C.Acute kidney injury
D.Hepatic impairment
Answer: B. Ischemic heart disease
Due to limited evidence, it is recommended that triptans be avoided in patients with hemiplegic or basilar migraine, ischemic stroke, ischemic heart disease, Prinzmetal’s angina, uncontrolled hypertension, and pregnancy. While a systematic review found no association between triptan use and risk of cardiovascular events, only four relevant studies were identified. Of note, all triptans should be limited to less than 10 days of use per month to avoid medication overuse headache.
A 54-year-old female patient complains of being “stressed out” at her new job. She reports daily headaches for several months and takes acetaminophen (Tylenol) to self-treat twice a day. She describes the headache as being band-like and dull and accompanied by tight neck muscles bilaterally. She denies nausea, vomiting, visual changes, and photophobia. Which of the following is appropriate management of this patient?
A.Advise the patient to slowly taper acetaminophen (Tylenol) doses to avoid withdrawal
B.Discontinue acetaminophen (Tylenol) and encourage stress reduction measures such as exercise and yoga
C.Advise the patient to increase the acetaminophen (Tylenol) dosage frequency
D.Start the patient on butalbital and discontinue acetaminophen (Tylenol)
Answer: B. Discontinue the acetaminophen (Tylenol) and encourage stress reduction measures such as exercise and yoga
Common pain relievers such as acetaminophen (Tylenol) may contribute to medication overuse headaches. Discontinuation of the overused medication is appropriate management. The patient should stop the overused medication and start preventive therapy using an alternative strategy (e.g., stress reduction). Acetaminophen (Tylenol) can be stopped abruptly. In contrast, do not abruptly discontinue opioids, barbiturates (e.g., butalbital), and benzodiazepines; decrease the dose gradually over a slow taper to avoid withdrawal symptoms and seizures. Butalbital is a barbiturate, which can also contribute to medication overuse headaches. Nonpharmacologic therapies should be initiated first, before starting additional pharmacotherapy.
A patient presents with a severe, unilateral, stabbing headache. The patient reports that the pain is localized in the periorbital region and also reports rhinorrhea. Upon physical assessment, ptosis and conjunctival injection are noted. Based on this clinical presentation, which of the following is indicated for initial acute therapy?
A.Ibuprofen (Motrin) 400 mg
B.Acetaminophen (Tylenol) 1,000 mg
C.Oxygen therapy at 12 L/min for 15 minutes
D.Propranolol (Inderal) 40 mg daily
Answer: C. Oxygen therapy at 12 L/min for 15 minutes
The patient is presenting with clinical features suggestive of a cluster headache. Clinical features include severe, unilateral, sharp or stabbing pain, with autonomic symptoms ipsilateral to the headache such as ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and/or nasal congestion. Initial acute therapy includes either oxygen inhalation or pharmacotherapy with triptans (e.g., subcutaneous sumatriptan) for treatment of an acute cluster headache attack. The acute treatment of a tension-type headache and mild-to-moderate migraine attacks includes simple analgesics such as ibuprofen (Motrin) or acetaminophen (Tylenol). Propranolol (Inderal) has been established as an effective treatment option for migraine prevention.
Which cranial nerve(s) (CN) is(are) responsible for tongue movement?
A.VIII
B. IX and X
C.XI
D.XII
Answer: D. XII
CN XII is responsible for tongue movement. The patient should be told to stick out their tongue; it should be midline. The nurse practitioner should be told to look for atrophy and fasciculations (small, involuntary, flicker-like movements of the tongue).
A patient presents following a seizure. A family member reports that the patient suddenly lost control of their leg muscles and fell to the ground. This finding suggests which type of generalized seizure?
Answer: A. Atonic
Subtypes of generalized seizures include absence (more common in childhood), clonic, myoclonic, tonic, and atonic seizures. Atonic seizures (also known as drop seizures) are characterized by a sudden loss of control of the muscles (usually the legs), which causes the patient to fall to the ground. Absence seizures are characterized by behavioral arrest along with staring and a blank facial expression. Clonic seizures cause rhythmic, jerking muscle contractions. Tonic seizures cause muscle stiffening along with impaired consciousness.
The clinician places a coin in the patient’s palm and asks the patient to identify the object with their eyes closed. This is an example of which test of cortical sensory function?
Answer: C. Stereognosis
Stereognosis tests the patient’s ability to identify a familiar object by touch. Graphesthesia involves writing a number or shape on the palm of the patient’s hand and asking the patient to identify what was drawn. Two-point discrimination involves using two ends of a cotton swab and touching the patient’s skin at various locations. The patient should be able to identify one- or two-point touch. Light touch tests primary sensory functions and involves lightly touching the skin and asking the patient to respond when and where the sensation was felt.
Which of the following tests evaluates cerebellar function?
A.Pronator drift
B.Stereognosis
C.Vibration test
D.Finger-to-nose test
Answer: D. Finger-to-nose test
The finger-to-nose test allows the clinician to test the accuracy of movements to assess for cerebellar function. Other coordination tests include rapid alternating movements, finger tapping, and heel-to-shin testing. Pronator drift is also a motor examination but assesses an upper motor neuron pattern of weakness that causes the arm to pronate and drift downward when the patient is asked to hold it extended with palms up. Stereognosis is a test of cortical sensory function; it assesses for the ability to identify a familiar object by touch (such as a key or a coin in the patient’s hand). The vibration test is used to test the sensory system by asking the patient to identify where the buzzing sensation is felt when placing a low-pitched tuning fork on various bony prominences.
Bell’s palsy is associated with dysfunction of which cranial nerve (CN)?
A.III
B.VII
C.VIII
D.XI
Answer: B. VII
Bell’s palsy refers to isolated peripheral facial paralysis (CN VII). Inflammation of the facial nerve causes weakness of the upper and lower portions of the face. The facial nerve allows for facial expression, taste, lacrimation, salivation, and ear sensation. CN III is the oculomotor nerve; CN VIII is the acoustic nerve; and CN XI refers to the spinal accessory.
