Week 3 Neurology Across the Lifespan Flashcards
You are watching a nurse practitioner examine a pediatric patient. You would expect the NP to assess the neurological system in which order?
Cerebral function, cranial nerves, motor function, sensory function, coordination, reflexes The neurologic examination moves from the highest level of functioning to the lowest. Cerebral function is tested first; then cranial nerves (CNs), motor function, sensory function, coordination; and finally reflexes.
You are collecting a history from a 4-year-old pediatric patient who presented with a neurological complaint. Which history would be considered to be the most accurate based on the developmental age of the child?
Since the child is 4, you collect a history from both the child and at least one family member. Historical information from children older than 3 years and from one or more family members provides the most accurate picture.
How do you assess the oculomotor, trochlear, and abducens?
pupillary response to light, EOM, ptosis
how would you asses the Glossopharyngeal, vagus
symmetrical risk fo soft palate, gag reflex
how would you assess spinal accessory nerve
turns head against resistance, shoulder shrug
How would you test the trigeminal nerve?
Sensation to light facial touch, temporalis, and masseter strength
how would you test vestibulocochlear nerve?
Weber & Rinne; whisper test
how would you test facial nerve?
symmetry of smile and rise of eyebrows, orbicularis oculi strength, strength with cheeks puffed out
how would you test hypoglossal nerve?
tongue protrudes midline
how would you test optic nerve?
visual acuity, visual fields, fundoscopic exam
What HA is often unilateral, and associated w/ nausea, photophobia or visual changes?
Migraine
What HA has pain behind the browbone and/or cheekbones?
Sinus
What HA has pain in and around done eye and occurs in bouts
cluster
what headache is like a band squeezing the head?
TTH
A patient reports two episodes of visual disturbances and eye pain that lasted 1–2 days each, about 2 months apart. Which diagnostic testing will the provider order initially?
MRI
A patient who sustained a head injury has a Glasgow Coma score (GCS) of 14. The patient’s spouse reported that the patient lost consciousness for approximately 7 minutes after falling down the stairs. A head computed tomography (CT) scan does not reveal brain lesions. Which treatment is indicated?
Admission to the hospital with a neurosurgical evaluation This patient had loss of consciousness longer than 5 minutes and has a GCS of 14; both are indications for admission to the hospital with a neurosurgery consult, even though the CT is currently normal.
The parents of a 4-year-old child bring the child to the clinic after observing a brief seizure of less than 2 minutes in their child. In the clinic, the child has a temperature of 103.1 °F, and the primary care pediatric nurse practitioner notes posterior pharyngitis and tonsilitis. A rapid strep swab is positive. The child is alert and responding normally. What will the nurse practitioner do?
Prescribe an antibiotic for the tonsilitis and reassure the parents
A child who has had a single, nonfebrile seizure has a normal neurologic exam. Which diagnostic test is indicated?
EEG
A child who has sustained a head injury after falling on the playground is brought to the clinic. The parents report that the child cried immediately and was able to walk around after falling. The primary care pediatric nurse practitioner notes slight slurring of the child’s speech and the child has vomited twice in the exam room. Which course of action is warranted?
Admit the child to the hospital for a neurology consult
A 35-year-old patient reports suddenly experiencing an asymmetric smile along with drooping and tearing in one eye. The patient has a history of a recent viral illness but is otherwise healthy. During the exam, the provider notes that there is unilateral full-face paralysis on the right side. What is the initial intervention for this patient?
Prescribe oral corticosteroids
What cranial nerve is responsible for tongue movement? CN VIII CN IX & CN X CN XI CN XII
CN XII
A possible complication of Bell’s palsy is: (pick one) Corneal ulceration Acute glaucoma Inability to swallow Loss of sensation on affected side
corneal ulceration
During a sports examination, a 16 year old patient is noted to have a few beats of horizontal nystagmus on extreme lateral gaze that disappear when the eyes move back towards midline. Which statement best describes this clinical finding? It is caused by occult bleeding of the retinal artery This is a normal finding It is a sign of possible brain mass This is a borderline result and requires further evaluation
This is a normal finding
Which of the following viral infections is associated with the occasional abnormal forms of lymphocytes during an acute infection? CMV EBV HPV Coxackievirus
EBV like in mono
A 65 y/o man presents to the clinic complaining of random and recurrent episodes of dizziness with nausea. The patient describes it as the sensation of the room moving or of the room spinning. It is worsened by sudden head movement. During the episodes, he becomes very nauseated. He also has tinnitus with hearing loss in his right ear. The patient has type 2 diabetes and is on a prescription of metformin and an ACE inhibitor. The blood glucose level during his visit is 80 mg/dL. Which of the following conditions is most likely? Vasovagal presyncopal episodes Meniere’s disease Atypical migraine Hypoglycemia
meniere’s disease (episodic vertigo, tinnitus, and sensorineural hearing loss (low frequency) May have the sensation of ear fullness
A 40 y/o male complains to the NP of severe stabbing pains behind his left eye for the past 2 days. They are accompanied by some nasal congestion and rhinorrhea, which is clear in color. The patient denies pharyngitis and fever. Which of the following conditions is most likely? Migraine HA w/aura Cluster HA Tic douloureux Cranial Neuralgia
cluster HA
Cardinal s/s: excruciating, unilateral, orbital, and or temporal pain.
Attack ranges from 15 mins to 3+ hours
ANS symptoms = ptosis, miosis, lacrimation and rhinorrhea in the nostril on the affected side of the face.
A 26-year-old female presents with fatigue, numbness and tingling in her bilateral upper extremities and feeling like she has difficulty maintaining her balance when walking. Upon further questions, she reports that she scheduled an appointment with optometry for an exam because of blurry vision. Which of the following should the primary care nurse practitioner consider for evaluating the patient’s symptoms?
Select one:
a. MRI of the brain with gadolinium
b. Imaging of the lumbar spine
c. Lumbar puncture
d. Electromyogram (EMG)
A
Which of the following should the nurse consider a red flag when evaluating an adult with a headache?
Select one:
a. Visual aura lasting longer than 15 minutes
b. A headache persisting for more than 4 weeks
c. Worsening pattern of headaches
d. Headaches that do not respond to over-counter analgesics
c. Worsening pattern of headaches
The nurse practitioner is educating an adult patient newly diagnosed with migraine headache. Which of the following statements should be included?
Select one:
a. You should take your abortive agent for headaches lasting longer than 4 hours
b. Use of your abortive agent more than 2 to 3 times per week can cause rebound headaches
c. We should consider preventive therapy if you have more than 15 headaches per month
d. We will need to order brain imaging and labs to confirm the diagnosis
b. Use of your abortive agent more than 2 to 3 times per week can cause rebound headaches
The primary care nurse practitioner is seeing a 46-year-old patient after they experienced a syncopal episode versus a first time seizure. The nurse practitioner understands that
Select one:
a. Epilepsy is diagnosed after the first unprovoked seizure
b. Epilepsy in adults is most often idiopathic
c. Loss of consciousness usually lasts seconds with syncope
d. Before a seizure, patients experience sweating and tunnel vision
c. Loss of consciousness usually lasts seconds with syncope
A 21-year-old patient who is currently being worked up by neurology for seizures presents to primary care for a follow up visit. During the visit the nurse practitioner witnesses a seizure episode in which the patient’s eyes and mouth are forced closed and there is preserved consciousness and response to painful stimuli. Which type of seizure does the nurse practitioner suspect?
Select one:
a. Tonic-clonic seizure
b. Absence seizure
c. Non-epileptic seizure
d. Atonic seizure
c. Non-epileptic seizure
Which of the following best describes Bell’s palsy?
Select one:
a. Paralysis of the lower portion of the facial nerve associated with ipsilateral hearing loss
b. Inflammation of the motor portion of the trigeminal nerve leading to weakness
c. Paralysis of the cranial nerve VII progressing over the course of 2 weeks
d. Unilateral, full facial paralysis with pain behind the ipsilateral ear
d. Unilateral, full facial paralysis with pain behind the ipsilateral ear
Migraine diagnosis
How many attacks?
How long do they last?
AT least 2=
at least 1-
Migraine Diagnosis
Migraine without aura = 5 attacks that fulfull…
Repeated attacks of headache lasting 4-72 hours (untreated or unsuccessfully treated), normal exam, and no other reasonable cause for HA
Recurrent HA separated by pain free periods
At least 2:
- Unilateral pain 60% of time
- Throbbing/pulsating pain
- Aggravation by movement/activity
- Mod-severe intensity
At least 1
- N/V
- Photophobia or phonophobia
how long does it take for preventative migraine treatment to work
8-12 for target dose
4-6 weeks to notice ad ifference
when is semiology?
what is symptomatic epilepsy?
What is cryptogenic?
Semiology: Used to classify type of behavior the patient exhibits during seizure
*most seizures are idiopathic*
Symptomatic: Seizures with identifiable cause (brain tumor, metabolic abnormalities)
Cryptogenic: Suspected to be symptoms but no MRI lesions (infantile spasms)
what does a frontal lobe seizure look like?
Broca?
Occipital?
frontal = movement/twitch
Broca = trouble speaking
Occipital = visual phenomenon
What is a tonic clonic seizure?
tonic phase?
clonic phase?
-
Tonic-Clonic (grand mal):
- Stiffening/jerking *you don’t have to have both*
- Symptoms: Stiffen up > air forced out > forced cry
- Tonic phase: bilateral stiffening
- Clonic phase: rhythmic jerking that starts faster
What is a simple partial seizure
Complex partial?
Simple partial: conscious; sensory complaints; others unaware pt is having seizure
- Gelastic Seizure: Hypothalamic hamartoma; uncontrollable laughter
Complex partial: loss of consciousness or “absent”
- May seem alert but not aware of what’s going on
- May have “automatic response”
- Automatism/automatic movements: move without purpose EX: pick at clothing
vagal nerve stimulator
Vagal Nerve Stimulator *most common
Pulse generator below clavicle
Connected to vagus nerve and delivers timed impulses
Neuropace
- Responsive Neurostimulator; less seizures over time
- Better control over seizures
- Similar to pacemaker; electorode on each temporal lobe
- Bitemporal epilepsy
Deep brain stimulation
Deep Brain Stimulation
- Parkinson & epilepsy
- Electrodes bilaterally on anterior nucleus of thalamus
- Preprogrammed
- Reduces seizure frequency over time
What AED interact with OCPs?
- Dilantin
- Phenobarbital
- carbamazepine
- Topiramate
- Lamotrigine
What is West’s syndrome?
“Triad”
What do the spasms look like?
Treatment?
Prognosis?
Appears 1st year of life
Triad: infantile spasms, hypsarrhythmia EEG pattern & developmental delay
Symptomatic (underlying structural cause)
Regression of developmental milestones
Spasms:
- sudden, rapid, tonic contraction of trunk at limbs <2 seconds
- Can occur in clusters separated by 5-30 seconds
- Spasms before sleep or upon wakening
Treatment
- Fewest seizures; fewest drug side effects
- Heavy Medication burden: ACTH, vigabatrin, Vitamin B6 an dprednisone
- Ketogenic diet
- Focal cortical resection OR hemispherectomy
Prognosis
- Poor
- Symptomatic disease = severe intellectual disability, Lennox-Gastaut syndrome, higher risk autism
What is Lennox-Gastaut Syndrome?
Cause
Type of seizures
Treatment
Cause: genetic; neurocutaneous syndrome; tuberous sclerosis; Encephalopathies after hypoxic ischemic insult (birth trauma); meningitis, severe head injuries.
Severe seizures in childhood
Multiple seizure types; usually tonic & atonic OR absence & myoclonic
- Developmental delay/regression
- Psychotic symptoms
- Normal development until 1st seizure
Treatment: *no drug very effective*
- Rufinamide
- Clobazam
- Carbamazepine: worsens drop attacks
- Ketogenic diet
- Corpus Callostomy
- VNS
