5) Neuro

Question 1

Anterior Cerebral Artery Stroke

Answer 1

• contralateral extremity weakness (lower > upper)
• altered mentation, reasoning
• bowel and bladder incontinence

Question 2

Middle Cerebral Artery Stroke

Answer 2

• contralateral face and arm weakness greater than leg
• contralateral sensory deficits
• dysphasia (if dominant brain hemisphere affected)

Question 3

Posterior Cerebral Artery Stroke

Answer 3

• contralateral visual field deficits
• altered mentation
• cortical blindness

Question 4

Vertebrobasilar Arteries Stroke

Answer 4

• vertigo or nystagmus
• dysarthria
• dysphagia
• contralateral pain and temperature sensory deficits
• syncope

Question 5

Tx of Ischemic Stroke

Answer 5

• IV, oxygen
• hypertension shouldn’t be treated unless severe (>220/>120) if you tx = nitroprusside or labetolol
• Aspirin if no contraindication
• IV thrombolysis (tPA) if ischemic stroke <3 h duration and w/o evidence of hemorrhage on CT scan of head

Question 6

Tx of Hemorrhagic Stroke

Answer 6

• Controversial to tx hypertension after hemorrhagic stroke

- most experts support reducing the BP to 140-160/80-90

Question 7

CSF characteristics in bacterial meningitis

Answer 7

Opening pressure >300mmHg
WBC >1000microliters
Differential >80% polymorphonuclear
Glucose 200mg/dL
Gram Stain Positive
Culture Positive

Question 8

CSF characteristics in viral meningitis

Answer 8

Opening pressure 40mg/dL
Protein <200mg/dL
Gram Stain Negative
Culture Negative

Question 9

Pathogens and Empiric Abx for Bacterial Meningitis in Neonates

Answer 9

Group B strep, E. coli, Listeria

Tx: Ampicillin and Cefotaxime

Question 10

Pathogens and Empiric Abx for Bacterial Meningitis in 1-3 mo

Answer 10

Strep Pneumo, n. meningitidis, h. influ

Tx: ampicillin, ceftriaxone, cefotaxime, and dexamethasone

Question 11

Pathogens and Empiric Abx for Bacterial Meningitis in ages 3 mo to 50y

Answer 11

strep penumo, n. mening, h. influ

Tx: ceftriaxone or cefotaxime, vanco, and dexamethasone

Question 12

Pathogens and Empiric Abx for Bacterial Meningitis in ages >50 or alcoholic

Answer 12

S. pneumo, Listeria

Tx: Ampicillin, ceftriaxone or cefotaxime and dexamethasone

Question 13

What is kernigs sign?

Answer 13

pain in the neck or back that occurs when a patient w/ meningitis attempts to stringed the leg at the knee when the thigh is held at 90degrees of flexion

Question 14

What is brudzinski sign?

Answer 14

spontaneous flexion of the hips during attempted passive flexion at the neck

Question 15

Gold standard for dx of meningitis

Answer 15

LP

• **all should have Ct of head to rule out mass lesion before LP
• **empiric abx must be started immediately, ideally within 30 min of the patients arrival to the ED

Question 16

Steroids in meningitis

Answer 16

Corticosteriods may be considered BEFORE initiation of antibiotic therapy in patients older than 1yr of age

Question 17

Prophylactic ABx for household contacts

Answer 17

(only for household contacts or those exposed to respiratory droplets, not routine daily contacts) offer to prevent subsequent infection in meningitis due to n. men:
-rifampin = recommended
alt =
-cipro = only for adults (bad for kid cartilage)
-ceftrixone

Question 18

Generalized seizures

Answer 18

originate from nearly simultaneous activation of both cortical hemispheres
(loss of consciousness and rhythmic tonic clonic)

Question 19

Focal seizures

Answer 19

initiate from a specific point w/in one cerebral cortex and manifest symp relative to to anatomic portion of brain affected

Question 20

Simple partial

Answer 20

consciousness is maintained

Question 21

Complex partial

Answer 21

loss of consciousness, indicates spreading or generalizing of aberrant neuronal activity to both cortical hemispheres

Question 22

SE

Answer 22

continuous seizure activity x 30 or greater without intervening return to normal baseline neuro functioning
(seizures that last >30-60 min may result in irreversible brain injury

Question 23

1st line agents for tx of active seizure

Answer 23

benzos (midazolam, lorazepam, diazepam)

short acting barbs (phenobarb, thiopental)

Question 24

2nd line agents for tx of active seizure

Answer 24

phenytoin/ fosphenytoin
magnesium (if thought to be from eclampsia)
valproate

Question 25

Drugs for refractory SE

Answer 25

Phenobarb infesion | isoflurane anesthesia

Question 26

Tx of migraines

Answer 26

Phenothiazines Ex: prochlorperazine (antiemetic and analgesic) - Serotin agonists Ex: sumatriptan (antiemetic and analagesic) * **avoid both of these if HTN, CAD, focal neuro findings

Question 27

RF for SAH

Answer 27

HTN, smoking, cocaine, first degree relative w/ dz, prior SAH **SAH has been associated w/ PCKD, connective tissue dz, coarctation of the aorta

Question 28

Patho of SAH

Answer 28

- arterial aneurysm usually within or near the circle of willis or AVM dilates and ruptures into subarachnoid space * *dural inflame may extend down the spine causing neck and back pain

Question 29

Tests for SAH

Answer 29

- CT is positive in 90% (most sensitive w/in 1st 12h) - SAH is 98% sensitive (most curate after 12h) * **if there is suspicion for SAH don't not stop w/ normal head CT, do LP***

Question 30

Tx of SAH

Answer 30

Operative resection or embolization - control HTN (nitroprusside, labetolol) - offer analgesics - often give phenytoin prophylactically for seizures

Question 31

Manifestations of temporal arteritis

Answer 31

- fever, malaise, weight loss, visual defects | * **ESR is usually elevated

Question 32

Tx of temporal arteritis

Answer 32

steroids to reduce inflam | **can lead to blindness if not recognized and tx promptly**

Question 33

Peripheral vertigo vs Central vertigo

Answer 33

peripheral =arises from the inner ear (more severe; positional, no associated headache) Ex: BPV, labrin, menieres central = arises from brainstem or cerebellum (mild but present longer, possible assoc HA, associated neuro findings) Ex: CVA, neoplasms, demyelinating dz like MS

Question 34

Cause of BPV and tx

Answer 34

free floating otoliths in semicircular canals -elderly Tx: antivertigo rx and epley maneuver

Question 35

Cause of labrythitis and tx

Answer 35

viral infection (#1), toxins: aminoglycosides, furosemide, NSAIDs -describe sudden onset of vertigo, nausea, and vomiting -nystagmus often present at rest Tx: tx underlying infection, stop toxic exposures, symptom relief

Question 36

Cause of meniere's dz and tx

Answer 36

-endolymphatic hydrops: extra endolymph in semicircular canals -late 20s thru early 50s -characterized by periodic severe vertigo, nausea, vomitng, tinnnitus, low frequency hearing loss and a sense of ear pressure or fullness **low frequency hearing loss Tx: supportive, and antiemertics **short course of steroids may be helpful long term = low salt diet diuretics are reserved for severe cases