Neurology I scenarios Flashcards
Your pt has been suddenly unarousable and unresponsible for the past 6 hours. Their reflexes are intact, and the cause of this state is believed to be a hemorrhage.
Assessment and Tx?
1) ABC’s: treat as necessary
-If hypothermic, rewarm and reassess
-CMP, blood gases; CT head, CTA brain
-Corneal reflex; Pupils
2) Tx: Support + correct any of the abnormalities found during assessment.
-Thiamine, dextrose, or naloxone can be given IV without awaiting lab results
You did a clinical exam on a pt but no tests. Can you diagnose them with brain death?
Technically yes (Dx is based on clinical exam; cerebral angiogram if needed)
Your pt sometimes appears to be unconscious and has sleep-wake cycles. Other times they appear to be awake, but never with any meaningful activity other than sounds. Pupillary light reflex is intact, but pt is incontinent. They had an anoxic brain injury prior to this state.
LOC?
Vegetative state
Your pt has inconsistent levels of consciousness; at times they have some self-awareness and have basic verbal communication and gestures. They can follow simple commands. They have been like this for the past two years.
1) What do you think the LOC and prognosis is?
2) Tx?
1) Minimally Conscious; unlikely to have any meaningful recovery (>12mo)
2) Underlying cause – if able, unlikely at this point
Amantadine
A pt in a coma has a unilateral (or bilateral) “blown” pupil; what cause of coma is likely?
Midbrain lesion or herniation
You believe your pt with a toxic or metabolic disorders is in a coma because of said disorder; what do you expect their pupils to look like?
Normal (usually)
Your pt in a coma has pupils that are small and responsive to light bilaterally. Likely cause?
Pontine lesion
Your pt’s motor function is absent other than their eyes, but their cognitive function is intact. They are mute and quadriplegic, but conscious.
Likely LOC? Prognosis?
Locked-In Syndrome; likely poor
1) A pt has damage to Wernicke’s or Broca’s areas. This likely caused a form of what?
2) What about if they had damage to their parietal, temporal or occipital lobes instead?
1) Aphasia
2) Agnosia (Inability to recognize things/people/places)
A pt can perform all the movements you ask of them in your PE, but does so incorrectly. Likely cause?
Can be widespread or focal cerebral damage (apraxia)
What may cause your patient’s prolonged or absent results on EMG?
Peripheral neuropathy
A pt has blood between dura and arachnoid meninges (bridging veins). This is called what? What would it look like on a head CT?
Subdural hematoma; crescent shaped bright bands on that DO NOT CROSS the midline
Jim, 64 with a Hx of alcoholism and epilepsy presents with ipsilateral pupillary dilation and contralateral hemiparesis. He said he just got in a fight at a bar and doesn’t remember much, but thinks he his head was injured.
Likely Dx? What about his med list do you need to check?
Subdural Hematoma; if he’s on anticoagulants
If you suspect a pt has a subdural hematoma, is the Glasgow coma scale an appropriate assessment?
Yes (<8 intubate)
Your agitated male pt has headaches that are episodic, severe, unilateral, rapid onset, periorbital pain daily for several weeks. They wake pt at night and get worse with activity, last 15 min- 3 hr, 1-8x/d x 4-8 weeks. Spontaneous remission then recur weeks to months later. He is also experiencing rhinorrhea and Horner’s syndrome. He unkindly states the bright lights of the urgent care are driving him insane.
1) Likely Dx?
2) Tx?
1) Cluster Headaches (trigeminal autonomic cephalgia)
2) high flow O2 via non-rebreather mask
Injectable sumatriptan 2-6 mg (max 12 mg/d)
Short term high dose steroids
High doses of verapamil
d/c smoking, alcohol
A 30 y/o female pt with a Hx of anxiety has a headache about one a month that can last up to 3 days for the past 6 months. She reports that it’s disabling, and that her mother had them too. She also reports rhinorrhea, blind spots, difficulty speaking, and neck pain. She feels like they happen in a pattern related to her menstrual cycle. Her neuro exam is normal.
1) Likely Dx?
2) Tx goal?
3) Txs?
1) Migraine Headaches
2) Eliminate pain and assoc symptoms without increasing disability. (ex/ avoid sedation;) early intervention; avoid known triggers
3) Acute: early use of high dose NSAIDs (though must weigh risks/benefits)
-Triptans** preferred nasal sprays or injections can be used in patients with n/v but are CONTRAINDICATED in CAD and cerebrovascular disease
-Combo therapy highest yield NSAIDs + triptans can also add metoclopramide or Compazine in pts with n/v as well
-Estrogen supplements for menstrual migraines
What should you avoid in treating your migraine pt?
Opioids for all pts; Triptans if CAD or cerebrovascular disease
A pt has the most common form of headache, which is what?
Tension
A pt has NO focal neuro deficits, but a bilateral band-like headache that is moderate, doesn’t pulsate, and doesn’t really get worse if they go to work. They have photophobia with it, but not phonophobia. The headache lasts anywhere between 30 minutes and 7 days depending on the episode; it’s happened over a dozen times abt 1 day a month.
1) Dx?
2) Tx? What Tx won’t work?
1) Tension headaches
2) NSAIDs, nonpharmacologic interventions (acupuncture, massage, trigger point injections, PT)
* Note, Botox does not work here*
Your pt has all the Sx of a migraine and an abnormal neuro exam. Should you Tx them for a migraine?
No; suggests secondary cause
A pt complains of dizziness. On PE you note nystagmus with no focal neuro deficits. You do an audiologic eval and test proprioception and vestibular system.
1) Likely Dx?
2) Tx?
1) Dizziness
2) Treat any underlying disorders
vestibular suppressant (meclizine)
antiemetics
Vestibular rehab
Last resort – intratympanic injections, surgery
A pt with DM presents with pain, vertigo, hearing loss, weakness, numbness, tingling or paralysis (facial drooping).
Likely Dx?
Tx?
1) Cranial nerve palsies
2) Decompression surgery, B vitamins 6, 12, correct underlying cause if able
A pregnant pt with DM has sudden onset of facial palsy (including their forehead) with impaired taste, pain near the ear may be present at the start for a couple of days. There are no other neuro deficits.
1) Dx and cause of Dx?
2) Tx?
1) Bells Palsy; inflammation of the facial nerve near the stylomastoid foramen
2) * 60% spontaneously resolve
*Prednisone 60 mg PO QD x 5d followed by 5d taper increases the chance of complete recovery by 1 yr
*Acyclovir or Valacyclovir if presence of herpetic vesicles in EACs
*lubricating eye drops
Riluzole 50mg PO BID, Edaravone can treat your pt with what really rare condition found in ALS pts?
Bulbar palsy
A pt has a functional disturbance of the brain but the structure is intact. This is called what? What is a key pt of treating this?
Concussion; repeat neuro checks
Which of the following is the keystone to management of your pt with a concussion?
A. medication for symptoms (esp. sedatives)
B. brief rest from cognitive and physical activity
C. hospitalize for monitoring
D. STAT neuroimaging
B. brief rest from cognitive and physical activity
(do NOT use sedatives!!)
Anxiolytics, antidepressants, cognitive and vocational therapy can help your pt with what condition that accompanies their concussion?
Post-concussion syndrome
A pt has contusional or perivascular bleeding within the cerebral parenchyma and and hypoxic-ischemic brain injury developed secondarily. Dx?
Traumatic Brain Injury (TBI)
A 27 y/o male patient presents with h/o HA, 2-3 times a month, lasting from 30 minutes to several days, bilateral band-like quality, mild to moderate intensity, not aggravated by routine physical activity (walking or climbing stairs). Denies N/V but does endorse some sensitivity to noise. Some improvement noted with Excedrin migraine tablets. Remainder of ROS & PMHx is non-contributory. PE non-focal
A. tension headache
B. migraine headache
C. cluster headache
D. secondary headache
A. tension headache
38 y/o male presents with h/o of disabling pain behind his right eye lasting about 60 minutes. He notes his eye gets red and tears and he becomes very agitated. Occurs several times a day for a couple of weeks then seems to go away for months then can return. HA gets worse with any activity. Remainder of ROS, PMHx is non-contributory. PE is non-focal
A. tension headache
B. migraine headache
C. cluster headache
D. secondary headache
C. cluster headache
