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FNP III - Test 1 > Module 5 > Flashcards

Module 5 Flashcards

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1
Q

Transient interruption of arterial blood flow to an area of the brain supplied by a particular artery with an episode of neuro dysfunction r/t focal brain, spinal cord, or retinal ischemia WITHOUT acute infarction or tissue injury; considered medical emergency

A

TIA

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2
Q

Risk of severe stroke highest within_____hours of TIA

A

48 Hours

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3
Q

Typically associated with focal neuro deficit and/or speech disturbance
Sudden onset of sx; typically last less than an hour (often just minutes)

A

TIA

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4
Q

Diagnostics for TIA

A

CBC, PT/INR, CMP, FBS, lipids, urine drug screen, ESR
Neuroimaging within 24 hours!!
* MRI preferred, CTA if MRI cannot be performed

Carotid duplex scan
ECG/echo/TEE (if afib expected)
Holter monitor for a fib

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5
Q

Predicts subsequent risk of TIA or stroke

A

ABCD2 Risk Score

Age: >60 (1 pt)
BP greater than or equal to 140/90 on 1st eval (1 pt)
Clinical sx: focal weakness with TIA (2 pt); speech impairment without weakness (1 pt)
Duration >60 min (2 pt); 10-59 min (1 pt)
DM (1 pt)

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6
Q

Management after TIA

A

Primary aim: decrease risk of subsequent stroke or TIA (PREVENTION )

Dual antiplt with aspirin and clopidogrel for 3 wks - 1 month followed by a single antiplt agent best antiplt plan for TIA pts

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7
Q

A LASTING interruption of blood circulation to the brain

A

CVA Stroke

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8
Q 
(13% all strokes)
More lethal, younger adults
HTN, trauma, drug use
Ruptured aneurysm, vascular malformation
HA prominent sx*
A

Hemorrhagic stroke

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9
Q

(~90%)
From HYPOPERFUSION
Older adults, pt with DM
Non-Lacunar: large vessel dx including carotids
Atherosclerosis most common cause
Thrombosis: embolism
Common RF: afib, valve replacement, recent MI

A

ischemic stroke

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10
Q

small vessel dx (intracerebral arterial system, distal vertebral and basilar arteries)

A

Lacunar: (ischemic stroke)

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11
Q

Immediate CVA stroke management

A

ED for CT w/o contrast to r/o hemorrhagic; IV thrombolytic therapy (TPA) within 6 hours of sx onset → best result within 3 hours, time is brain! Mechanical thrombectomy

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12
Q

Primary care role post CVA

A

1st visit should be soon after d/c from acute care/rehab within 1-3 wks
Screen for: complications
continue antiplatelet
Screen at ALL apt for stroke RFs

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13
Q

An acute fluctuating syndrome of altered attention, altered awareness and cognition in the patient
Commonly found in older persons in hospital or long term care settings
May indicate a life threatening condition

A

Delirium

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14
Q

3 forms of Delirium

A

Hyperactive= Confusion, agitation, hallucinations, myoclonus

Mixed= Fluctuates between both

Hypoactive = Confusion, somnolence, withdrawn

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15
Q

amyloid plaque and neurofibrillary tangles. Atrophy of cerebral cortex.
Earliest sign: short term memory loss

A

Alzheimer - dementia

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16
Q

multiple areas of focal ischemic change

A

vascular dementia

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17
Q

proteins that enter neurons and cause cell degeneration and death. Loss of dopamine producing neurons (like parkinson) and loss of acetylcholine (like Alzheimer)
present with visual hallucinations, motor impairments, postural instability, and sleep disturbances
Increase sensitivity to neuroleptics: haloperidol

A

Lewy body Dementia

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18
Q

2 or more brain functions (typically memory loss and language skills) impaired without a loss of consciousness

A

Dementia

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19
Q

depression in older adults leading to memory loss, attention deficits, and problems with initiation

A

Pseudodementia

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20
Q

Dx Dementia

A

MMSE- > 24-30: no impairment; 18-23: mild impairment; 0-17 severe impairment
Clock drawing, mini cog, geriatric depression test, remember words
cognitive testing

Thorough history/neuro exam; assess ADLs (Have fam member present for evaluation)

Labs: CBC, CMP, TSH, B12, folate, Ca***
Non contrast CT or MRI- recommend a baseline brain imaging
Additional tests: neuroimaging, CSF analysis, lyme tite, RPR

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21
Q

Pharm tx for dementia

A

Acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine)
Memantine (namenda)
SSRI for depression

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22
Q

Nonpharm tx for dementia

A

Cognitive training; lifestyle behavioral interventions; exercise; educational interventions; multidisciplinary interventions; shared group visits

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23
Q

group of monophasic immune mediated peripheral neuropathies
Demyelinating neuropathy
Acute inflammatory polyradiculoneuropathy
Miller Fisher syndrome- oculomotor nerve myelin affected
Axonal: axon is targeted rather than myelin sheath. Most common.

A

Guillain-Barre Syndrome

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24
Q

⅔ of the time follow an upper respiratory or gastrointestinal infection
Common virus: CMV and EBV
Bacteria: Campylobacter jejuni (23% to 45%), Mycoplasma pneumoniae (5%), and Haemophilus influenzae.

A

GBS

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25
clinical presentation of GBS
Symmetric paresthesia and weakness starting in the LOWER extremities and evolving over hours to days...Weakness spread to upper extremities/ deep tendon reflexes, then respiratory muscles, and finally paralysis Weakness peaks at 3 WEEKS
26
incoordination in extremities and weakness of eye movements with double vision. Recover more quickly and completely. Areflexia, ataxia, and distal paresthesia.
MFS (Miller Fisher Syndrome)
27
form of GBS preserved reflexes and tend not to have pain
Acute Motor Axonal Neuropathy (AMAN
28
Most important confirmatory test for GBS
LUMBAR PUNCTURE Albuminocytolic dissociation: elevated CSF protein with some increase of mononuclear CSF WBC acutely : polymorphonuclear leukocytes
29
Tx of GBS
hospitalization: monitor progressive weakness, provide supportive care, and manage potential complications Immunologic treatment: IVIG or plasma exchange - reduces the duration of mechanical ventilation and hastens recovery Corticosteroids are NOT indicated Evaluate strength using 5 point Medical Research Council scale Physical, occupational, and speech therapy
30
_____ metastases are more prevalent in non-SCLC and breast cancer due to the higher incidence
Brain ``` Astrocytoma (20.3%) Oligodendroglioma (1.4%) Ependymoma (1.8%) Meningioma (36.8%) Primary CNS lymphoma (2 %) ```
31
Peritumoral edema- risk for brain herniation Seizure common presenting symptom glioblastomas = fast growing tumors will show abrupt symptoms Focal changes = deficits in vision, speech, strength, sensation, or gait Nonfocal= headache, memory loss, behavior change, cognitive deficits and fatigue Papilledema= may indicate increased intracranial pressure
CM of intracranial tumors
32
physical exam for intracranial tumors
Occipital and parietotemporal: visual field testing Frontal or parietal lobe: motor and sensory abnormalities Frontal or temporal lobe: aphasia Posterior fossa- gait dysfunction or disorders of coordination
33
Dx for intracranial tumors
CT head with contrast Brain MRI with or without contrast (with gadolinium is gold standard) *** Tissue acquisition- to establish diagnosis and render treatment Concern for metastatic disease- CT scan of chest, abdomen, and pelvis or PET scan
34
Chronic, progressive, inflammatory neurodegenerative dx that affects the CNS Hallmark lesion: Plaque Patients at high risk for other autoimmune disorders: DM, RA, osteoporosis, frequent UTI, obesity, depression, and thyroid disease
MS
35
Some neuro sx, lasts ~24 hours, 1st one experienced, typically no diagnosis yet Would see maybe 1 lesion on MRI if obtained Most in CIS have 60-80% of full blown case in next 5 yrs
Clinically isolated syndrome (CIS) | 1st course/ event of MS
36
Most common course; 85% diagnosed in this category attacks/periods of sx → get better/resolve → cyclical NO progression; episodic cases of sx Typically 20’s-30’s; can stay in this course for a while (~10 ye
Relapsing-remitting MS (RRMS)
37
Attacks causing nerve damage; dx worse → damage staying Proressive damage to nerves Can be gradual transition from RRMS to SPMS
Secondary-Progressive MS (SPMS)
38
Worsening neuro function from beginning of symptoms Start here and stay here! 40’s-50’s typically when seen; already have permanent nerve damage More difficulty with walking, working, performing ADLs
Primary-Progressive MS (PPMS)
39
electrical shock sensation down spine when bending neck forward
Lhermitte’s sign | can be MS sign
40
tightening sensation around torso; can feel very restricting
Dysesthesia (“MS hug”)
41
Multiple Sclerosis exam?
Mental status, neuro (eyes: EOMs, nystagmus; fundoscopic exam; trigeminal neuralgia; CN 7 dysfunction; sensory; romberg; cerebellar; reflexes), MS Documented neurologic and functional baseline for evaluation of response to treatment or possible exacerbation of disease
42
Multiple Sclerosis diagnostics?
``` Clinical diagnosis MRI with gadolinium = gold standard for diagnosis of MS via the McDonald criteria CSF analysis (oligoclonal bands) Final diagnosis done by neurology by McDonald criteria ``` Refer to neurologist, MS neurology expert, or MS center for confirmation of diagnosis
43
For MS... Incidents defined by time and space Episode lasting 24 hours, 30 days apart (time) Evidence of 2 locations affected (space) Also need NO other reason for patient’s sx
McDonald Criteria
44
Multiple Sclerosis management?
Goal of therapy: reduce # of attacks and progression of disease + sx management DMT initiation starts as early as possible with the first presentation of, usually, CIS. The use of DMTs is not recommended during pregnancy or while breastfeeding. Stop three months before conceiving Exacerbation treatment: high-dose intravenous steroids for a short period or adrenocorticotropic hormone (ACTH) Lifestyle modifications: A low-sodium diet and smoking cessation
45
autoimmune disorder that produces an immune-mediated neuromuscular blockade or neuromuscular junction disorder ... circulating receptor binding antibodies decrease the number of available acetylcholine receptors on the postsynaptic muscle membrane or motor end plate, leaving the motor end plate less responsive
Myasthenia Gravis
46
symptoms are permanent, no remission, but does not experience myasthenic crisis Respiratory insufficiency, dysphagia, hypotonia, weakness, poor spontaneous motor activity, weak cry, poor sucking, choking, expressionless face, and absent Moro reflex.
Congenital Myasthenia Gravis
47
1st symptom of MG followed by...
Ptosis or extraocular muscle weakness double vision, fatigue when chewing, slurred speech, snarling appearance when smiling, weakness of limb girdle and distal muscles of hands.
48
In Myasthenia Gravis... Rapid muscular fatigue as evidenced by inability to:
- Hold an upward gaze for 30 to 90 seconds - Sustain a chin to chest position while supine - Maintain arm abduction for more than 1 to 2 minutes - Sustain rapid hand-fisting movements for long periods of time
49
Diagnostics for Myasthenia Gravis
short-acting cholinesterase inhibitor (edrophonium chloride) is given as a clinical test (should cause spontaneous improvement in the ptosis ) ; EMG AchR antibody testing (often inconclusive) thyroid profile CK level (normal with MG); chest x-ray (any enlarged thymus needs to be followed up with a tomography or CT scan of the anterior mediastinum); ECG (should be normal); muscle biopsy may be considered.
50
Tx for Myasthenia Gravis
Anticholinesterase therapy: Pyridostigmine Treatment goals not met: corticosteroids or immunosuppressants therapy Symptoms that are severely debilitating: corticosteroids, cytotoxic agents (azathioprine and cyclosporine) or thymectomy
51
Complications r/t Myasthenia Gravis
Corticosteroid use- growth retardation Thymectomy- immunodeficiency in adulthood Long term therapy with anticholinergic- cholinergic crisis similar to myasthenic crisis Myasthenic crisis: worsening muscle weakness, resulting in respiratory failure and requires a vent.
52
``` Cardinal features: (motor) Tremor at rest (hands, fingers, forearms, feet) Muscular rigidity Akinesia (bradykinesia) Reduced arm swinging Shuffling gait with short steps Masklike faces (expressionless) Loss of postural reflexes Flexed posture; forward tilt trunk Other CM: fatigue, depression, sleep disturbance, dystonia, hypophonia, drooling, impaired cognition, dysphagia, dystonia ```
Parkinson's Disease
53
How to dx parkinsons
CLINICAL; thorough hx and neuro exam Positive response to dopaminergic tx supports diagnosis (levodopa) Must have 3 supporting sx Typically unilateral onset with persistent asymmetry Presence of tremor at rest Gradual sx progression No lab test indicated CT/MRI only if you suspect structural lesion → do not confirm PD diagnosis
54
Primary Pharm tx for parkinsons
Gold standard: levodopa + carbidopa Goal: neuroprotective tx
55
sense of inner general restlessness reduced or relieved by moving about = inability to remain still.
Akathisia
56
brief flap of outstretched limb, transient inhibition of the muscles of posture
Asterixis
57
unsteady or swaying motion
Ataxia
58
slow, writing, continuous, involuntary movement
Athetosis
59
involuntary, irregular, nonrhythmic movements that seems to flow from one body part to another
Chorea
60
abnormal involuntary movement
Dyskinesia
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A sustained involuntary muscle contraction that results in twisting movement and posture, often patterned and repetitive.
Dystonia
62
Sudden, irregular, involuntary jerking of the muscles.
Myoclonus
63
A fine quivering or rippling of muscles. Common and benign in facial muscles.
Myokymia
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A coordinated movement that repeats continually and identically. Compulsion.
Stereotypy
65
An oscillation, usually rhythmic and regular
Tremor
66
most common movement disorder | Can be caused by my meds, psych, substances, etc; rule everything out!
essential tremor
67
Akinetic, hypokinetic, or bradykinetic syndromes (parkinson disease, depression, hypothyroidism)
​​Insufficient Movement
68
Myoclonus, encephalopathy, chorea (Huntington disease) , and tic disorders (Tourette syndrome, complex partial seizures)
Too Much Movement “Jerky”
69
Dystonia and tremor (essential tremor, metabolic disorders, medication, genetic, stroke, MS, tumor)
Non-jerky movement
70
diagnostics for Movement disorders
Clinical diagnosis Initial studies: CBC with differential, CMP, and thyroid studies to r/o medical or metabolic abnormalities Infection workup: CBC, urinalysis, chest xray Drug or alcohol: toxicology screen, ammonia level, LFTs Neurologic findings: CT scan of head
71
Criteria for dx movement disorder
- Tremor of the hands and forearms or at least one arm (postural or kinetic tremor) - Detailed hx regarding tremor, fam hx, social hx (alcohol, caffeine, drug use) and meds - Absence of other neuro signs/etiologies (Parkinsonism, dystonia, alcohol, meds)
72
Essential tremor: Pharm management 1st = 2nd= other
1st Propranolol Reevaluated propranolol after 1-2 weeks Anticonvulsant (Primidone) next option if beta blockers are not effective and can be in combined therapy with propranolol clonazepam/alprazolam can be used with caution Atenolol, gabapentin, sotalol, topiramate considered for limb tremor
73
Essential Tremor: Nonpharm
Surgical deep brain stimulation, focused ultrasound ablation, radio frequency ablation, and stereotactic radiosurgery Alcohol Avoid stimulants such as caffeine, soda, and coffee, OTC allergy and cold preparation Screen for alcohol abuse
74
Distressing “creepy-crawly” sensation in the legs. Irresistible urge to move the extremities. Can cause chronic insomnia familial , idiopathic, or associated with disorders (pregnancy, renal failure, and low iron stores ferritin levels < 75 or transferrin < 17) (also peripheral neuropathy and parkinson disease)
RLS
75
RLS has four principal diagnostic criteria.
1. Urge to move the legs, uncomfortable sensation 2. Urge begins or worsens during inactivity or rest 3. Ameliorated by activity or movement such as stretching or walking 4. Urge or sensation are worsened in evening or at night
76
diagnostics for RLS
IRON STATUS- associated with RLS Fasting serum iron, total iron binding capacity, ferritin, and transferrin saturation RLS is clinical diagnosis PSG may offer supportive information of the diagnosis
77
pharm tx for RLS
First line***** and may help with neuropathy= Alpha 2 delta ligands- gabapentin, pregabalin, and gabapentin enacarbil (only FDA approved for RLS) First line in patients with concomitant depression or who is at higher risk for falls = Dopamine agonist: pramipexole, rotigotine, and ropinirole Screen for impulse control disorder Opioids, carbamazepine, and clonidine Supplement iron
78
genetic neurodegenerative disorder characterized by developmental arrest and regression and multisystem comorbidities Mutation in the X-linked, methyl- CpG=binding protein 2 (MECP2) gene Also: CDKL5 and FOXG1 genes
Rett Syndrome
79
Early red flag- head growth deceleration Seizures, scoliosis, sleep disturbance, GI dysfunction, resp dysfunction bruxism, apraxia, gait abnormalities, and stereotypic hand movements (e.g., wringing/squeezing, clapping/tapping, hand-mouthing or biting and handwashing/rubbing automatisms).
Rett Syndrome
80
main criteria for dx rett syndrome
consider diagnosis when postnatal deceleration of head growth is observed. Based on main criteria - Partial or complete loss of acquired purposeful hand skills. - Partial or complete loss of acquired spoken language** - Gait abnormalities: Impaired (dyspraxic) or absence of ability. - Stereotypic hand movements such as hand wringing/squeezing, clapping/tapping, mouthing and washing/rubbing automatisms Due to risk for seizures: screening EEG is advised with diagnosis
81
Complex neuro disorder with uncontrolled electrical disturbance in the brain Single seizures: high fever in small children, hyponatremia, hypercalcemia, hyperventilation in susceptible patients, or alcohol withdrawal.
Seizures
82
continuous convulsive seizure for five minutes, continues focal seizure for 10 minutes, and continuous absence seizure for 10-15 minutes
status epilepticus
83
when to dx epilepsy
after 2 or more seizures that are not brought on by an identifiable cause Generalized: affect both sides of the brain Focal: partial seizures; located in one area of the brain
84
When should you call 911 with seizure
1st seizure; difficulty breathing/waking after seizure; >5min; another seizure soon after 1st; pt hurt during seizure; happens in water; comorbidities (DM, heart dx, pregnant)
85
Seizure pharm management
Levetiracetam (Keppra); Fosphenytoin/phenytoin (Cerebyx); Valproic acid (depakote), Lamotrigine (Lamictal) When medications are changed, the new medication should be added to the existing regimen. When the new medication is well tolerated and an effective dose has been achieved, the first medication can be slowly reduced.
86
caudal end is fixed by a ropelike filum terminale at or below the L2 level Associated with congenital spinal anomaly: spina bifida Result from: bony protrusions, tough membranous bands, lipomas, tumors, trauma in the cauda equina
Tethered Cord
87
Gold standard dx for tethered cord tx?
MRI of spine refer to neurosurgeon hx of repaired spina bifida must closely be monitored for tethered cord
88
CM of Tethered Cord
not all leads to symptoms Lesions, hairy patches, dimples, or fatty tumors on the lower back; foot and spinal deformities; weakness in the legs; low back pain; scoliosis; and incontinence
89
Benign, chronic neurologic condition that involves symmetric, rhythmic trembling of the upper extremities, head, or voice. Emotion stress increase symptoms and alcohol decrease symptoms
essential tremor

FNP III - Test 1 (6 decks)

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