Neurology Exam 2 Flashcards Preview

Neurology > Neurology Exam 2 > Flashcards

Flashcards in Neurology Exam 2 Deck (132):
1

Identifiable factors of Primary Headache

No obvious underlying cause; Chronic, recurrent and usually no other signs or symptms of nerologic disease; Can have familial relationships.

2

What defines a Secondary HA

Headache associated with underlying cause

These warrent more extensive work up
Neurologic symptoms
Abnormal Mental status
Red Flags
Fever

3

The following are examples of diseases or processes that can cause what?
intracranial lesions, Head injury, Dental, Ocular disease, Tumors, infection, Meningitis, Subarachnoid Hemorrhage, Temporal Arteritis, Sinusitis, Carbon Monoxide Poisoning, Alcohol, Hypoxia

Secondary Headaches

4

2.1 - Read Approach to HA's OLDCARTS - good examples of questions to ask to find or eliminate serious problems or red flags.

OK

5

Important PMH questions for HA

Migranes or headaches, anticoagulants, HIV, Medications, Immunosuppressed, Cancer Pregnancy, Drug abuse

6

Family history Questions for HA's

Migraines, SAH

7

Social history that can help with diagnosis of HA's

Alcohol use, illicit drug use, cocaine, meth, environmental exposure. MenstruationHistory, Sexual History.

8

Make sure that you ask this question to every pt that has HA's

Is this a typical HA for you?

9

Important factors for physical exam

Perform and then document a comprehensive Neurologic Exam
Fundoscopic exam
Intraocular pressure mesureed with Tonometry
Palpate the Temporal Artery - Temporal Arteritis

10

Diagnostic Studies that can be performed for HA's

CT, MRI, Lumbar Puncture,
Labs- CBC, CMP, ESR, CRP
CsF pressure and analysis, Presence of Blood in CSF

11

What is the most Common type of Primary HA

Tension Headache

12

Which headache is known to have a Band-like tightness or viselike tigtness

Tension Headache

13

What are the ages that are associated with Migraine vs Tension HA

Onset of age of Migraine is typically a younger age

Tension HA's aree more common to present in adults.

14

What are some factors that make Tension HA worse

Stress, Fatigue, Noise, Glare

** high correlation with Dep. and Anxiety

15

Diagnosis key points for Tension HA

Band-like / Vice-like tightness, bilateral, predominantly frontal or ocipital location. Can be generalized, and not usually characterized by worsening with activity.

16

What are the Three categories of Tension Headache

Infrequent, Frequent, Chronic (daily)

17

Tx of Tension HA's

NSAIDs / Tylenol
Dose of Toradol 30-60 mg IM works well in primary care setting
Amitriptyline Prophylactically
Dihydroergotamine
Avoid opioids
Treat comormid depression or anxiety
Triptans not indicated
Massage, acupunture, improved sleep
Headache Cocktail

18

Males or females more preominantly effected with Cluster HA

Males typically aged 20-50

19

s/s of Cluster headache

Severe unilateral HA that has a patterened timing and or clusters

20

What is the pathophysiology of Cluster HA

The pathophys of cluster headaches are unknown

21

Cluster HA's can be triggered by alcohol true or false

True and false- during fits.. it can.. but when there is remissin of the headaches it does not

22

Cluster headaches are described as whta

the worst pain a human can experience

23

Is a Cluster HA unilateral or Bilateral

Unilateral

24

Which HA is considered to be an "alarm HA"

Cluster HA as t often happens at night

25

Autonomic symptoms during a cluster headache

Ptosis, miosis, conjnctival injection, lacrimation, nasal congetion, rhinorrhea

26

TX for a Cluster HA

100% O2, Verapamil, Ergotamine, Intanasal Lidocaine, Vagus nerve stimulation, Intranasal Triptan

Prophylactic- Verpamil, prednisone taper, Lithium

27

What are the two main categories of of Migraines

Migraine with Aura (this is the "classic migraine"
Migraine)- less common

Migraine without Aura- "common migraine"

28

Phases Of a migraine

Prodrome - 60% of people report pre-symptoms

Aura- usually visual disturbance but can be sensory, motor

Migraine phase

Postdromal - feeling tired, euphoric, weakness, food cravings, or anorexia (24hrs)

29

What is scintillating scotoma

(enlarging blind spot with shimmering edge)

30

What symptoms o people get with the prodrome phase of a migraine

sinsityvity to light and sound, fatigue, food cravings, mood changes, excessive thirst, anorexia, etc.

31

What Is a common discription of a migraine headace

Unilateral pulsating HA

32

How many attacks must a person have to diagnose recurrent Migraine

At least 5 attacks that can not be attributable to a secondary cause

33

what are other characteristics (other than unilateral pain and throbbing that are associated with Migraine)

Nausea, vomiting, photophobiea, phoophobia, will lay still in a dark room to try to get it to go away, comes on gradually and lasts for hours,

34

TX of migraine

The earlier the better- Triptans, NSAID, Tylenol, Caregrot- Ergotamine/Caffine

Hadache Coctail
Darken room/limit noise
Acupuncture- some consider this almost as effective as western edicine
Oxygen

35

What is in A HA cocktail

IV normal Saline 1 L
Benadryl 25 mg IV
Reglan 10mg IV
Toradol 30 mg
with or without Magnessium 2mg IV

36

Prophilaxis of Migraines

If migraines are frequent (more than 2 times a month) and or debelitating use prophylaxis

Avoidance of triggers
sleep maintenance
Medicaiton
Botox injetions
Acupuncture(evidence based)
Nerotrimulation

37

Medcations that are common with treatment of Migraines

Triptains- 5-hydroxytyptamine (5HT1) agonist
Ergotamine- alkaloid derived from a fungus

AntiSeziure meds - thought to supress firing of involved nerve endings
B-Blocker- propranolol- most common

38

What is the MOA for a Analgesic Rebound HA

The pt builds a tolerance in the presence of Chronic pain medication use.
The pt will feel frequent possibly even daily headaches that arise becaue of the tolerance. (this does not qualify them as an addict, simply they are having symptoms from withdrawal because of tolerance)

39

TX for Analgesic Rebound HA

Generalloy requires withdrawal, often slowly is desired to prevent seizures and other adverse effects from withdrawal

40

How many days or months typically are involved to diagnose as a Rebound HA

15 days straight
or HA's for greater than 3 months

41

What are HA RED FLAGS

Sudden onset - thunderclap or via trauma, or during exertion
Altered mental status
seizure
Fever
Neurologic s/s
Visual Changes
Medications- Anticoagulants/ Antiplatelets
Immunosuppression- medications, HIV, etc
PMHx- no prior HA history, or a change in HA quality or progressive
PMHx- Lupus, Cancer
Pregnancy (MRI no contrast)
Physicalexam- neck stiffness, Papilledema

42

Common indications to get immaging for HA's

Change in status or first /worst
Abnormal neuro exam
fever/immunosuppressants-brain abscess
Onset of migraines over 50
Stick neck
Awakening from sleep
Changing in position
Previaous cancer diagnosis
Seizure
Personality change or int. or cognitive deficit
hypertension

43

Contrast or no contrast for a brain MRI

Contrast is preferred- order with this if they dont want it radialogist will change it as appropriate for probable diagnosis

44

When is Noncontrast head CT preferred

Trauma
Thunderclap HA
New HA w/ neuro def.
Chronic HA w/ change in features
Sensitivity drops over time given resorbption of blood/

45

What are the causes of a thunderclap HA making it a Red Flag symptom

Subaracnoid hemmorrhage
cerebral venous thrombosis

46

What is the 20 day survival rate of pts that expereience a subarachnoid hemorrhage

50% of the 50 percent of survives 50% of those pts will have neurologic impairment

47

Which arteries tearing or having aneurysm cause subarachnoid hemorrhage

Arteries that provide to teh Circle of Willis.

48

Is it common to catch or miss SAH

Kown to be easily missdiagnosed, with devastating consequences.

49

symtoms to help diagnose SAH

Suden headache with maximum intensity reached within 10 mintues (SAH until proven otherwise)
with or without AMS
Vomiting
Hypertension
Stiff neck
Severe distress

50

What is the rule that is used to help Identify Subarachnoid hemorrhage

Ottawa Subarachnoid Hemorrhage Rule

51

What all is within the Ottawa Subarachnoid Hemorrhage Rule?

Age >40
Neck pain or stiffness
Witnessed LOC
Onset during exertion
Thunderclap HA
Limited Neck flexion on PE

52

Diagnositc studies for Thunderclap HA

Non-Contrast Head CT initial test for suspicion of intracranial bleed
Lumbar Puncture- looking for blood or xanthochromia in CSF

53

What should be considered if CT and LP is negative when you believe the pt is presenting with a subarachnoid hemorrhage ( this is done because it is possible to get negatives and still truely have the bleed so base off suspicion level of bleed)

CTA
MRA

54

what all can a space ocupying lesion in the brain be

Malignacny, abcess, hematoma, or otherwise.

55

What is the definition for a space occupying lesion

Displacement of normal brain tissue, being that space is limited within the enclosded skull - tumor, mass lesion malignant or not can be an abcess hematoma or other..

56

What are the symptoms fo A space Ocuppying lesion

symptoms can vary... the symptoms present will coordinate to the location of the lesion

57

what is the most common finding when there are HA's with neurologic change or dysfunction

Tumors

58

What are the diagnostic studies warrented for a possible space occupying lesion

CT, MRI with contrast, Labs- CBC , CMP, LP- delay til after CT to prevent death if actually have hHA's because of space occupying lesion, Compreshensive Neuro exam, neurosurgical consultation

59

What is another name for Temporal Arteritis

Giant Cell Arteritis, - it is considered a systemic panarteritis which commonly affects the temporal artery. Subacute inflammatory change seen with lymphocytes, mononuclear cells and giant cells. Leads to thrombosis of the artery.

60

What is common for uncontrolled / untreated temporal arteritis to lead to

Blindness d/t ischemic otic neruopathy.

61

What is the way to diagnose Temporal Arteritis

Arterial Biopsy

62

Common Diagnosis keys for Temporal Arteritis

Age > 50
New HA
Tenderness when palpating over the artery, decreased pulsation
ESR > 50 mm/h
Abnormal Artery Biopsy

63

Key PE findings for Temporal Arteritis

Palpate over artery for tenderness, throbbing unilateral, with or without bilateral HA, with pain localized to the temporal scalp
Asymmetry of pulses
US, MRA, CTA have been used to demonstrate narrowing of the arteries

64

Management of Temporal Arteritis

IV steroids, followed by oral steroid. These must be started promptl to prevent co-morbidities
Steroid taper given over several weeks
Diagnosis should be revisited if there is poor response to corticosteroids

65

what can cause a CNS infection

Bacteria
Viral
Fungi
Protozoa
Spirochetes

66

what conditions are included within CNS infection

Meningitis
Encephalitis
Brain Abscess
Epidural Abscess

67

Wha Diagnostic studies should be completed when DDX is thought to be CNS infection

CBC, CMP
Blood cultures (prior to antibiotics unless you cant prevent a negative outcome)
Neuroimmaging- CT, MRI, Chest X-ray
LP- if lesion not detected (do not delay antibiotics for LP)
Viral antibody testing
Sepsis protocol

68

What all is used for Sepsis

SOFA - sequential Organ failure Assessment

SIRS Cirteria - Fever >100.9 0r <96.8 ; HR >90 ; Tachypnea >20 or PaCO2 < 32 mmHg ; WBC >12k or <4k

69

Lab studies when you suspect sepsis

CBC, CMP, Lactic Acid, ABG, PTT, PT/INR, Lipase, LP w/ CSF analisis and cultues, Urinalysis and cultures, blood cultures, CXR

70

Sepsis Clinical Criteria - SOFA change in the SOFA ≥ what number

2

71

Major symptoms leading to diagnosis of Meningitis

Infection of meninges
HA accompaned by fever, stiff neck (nuchal rigidity), and sometimes alterd mental status ( low sensitivy to bacterial meningitis)

72

Common bacterial infections associated with bacterial meningitis

Streptococcus, Neisseria, Listeria, Gram- neg bacilli

73

Common viral pathogens associated with miningitis

Herpes, enteroviruses, Mononucleosis, Prior to MMR, mumps as the mC virus

74

how is a Diagnosis made of meningitis

Made with a gram stain smear of the CSF obtained from LP
CBC, CMP, Blood cultures, CsF analysis and culture, and CXR

75

who is Encephalitis worse for (what pt population)

the age extremes - very young and very old

76

Viral Prodromes of Encephalitis include:

Fever, HA, Neck pain, Back Pian, Nausea, Vomiting, Lethargy, May have a viral Rash

77

If encephalitis is present along with meningitis what do we call this?

Meningoencephalitis

78

what are the causitive pathogens of encephalitis

MC are viral, but they can be caused by bacterial fungal, autoimmune
Herpes- Tzanck Smear
Rabies- virtually 100% fatal
West Nile Encephalitis
Japanese Encephalitis
Measles
EBV
Influenza

79

diagnostic tests for Encephalitis

CBC, CMP, Blood Cultures, CXR, CT, MRI, Viral Antibody testings, LP with viral and bacterial cultures of CSF

80

Diagnosis of Brain Abscess

Also considered a space occupying lesion
Presentation similar to other space occupying lesions, with likely fever or infectious suspicion

81

What causes Brain Abscess (pathogens)

Caused by any number of bacteria, fungi, protozoa

Higher risk in HIV patients

82

Neuroimaging with contrast for Brain Abscess

MRI is better, CT is faster (repeated to insure resolution)

83

Risk for herniation if LP is performed (and LP may not be helpful) in what situation and secondly what immaging should be performed prior to

If there is a brain occupying lesion
Get a CT prior to LP to prevent death from herniation of brain down on the brainstem via pressure change

84

Which Things do we want prior to empiric antibiotics when we suspect a brain abscess

CBC, CMP, Blood Cultures

LP -if possible without delaying antibiotics
and blood culture should not delay life saving intervention of pts

85

usually brain abscesses are preceded by prior infections ... these spread by what 3 ways

Contiguous (i.e.sinusitis), Trauma, Hematogenous

86

Treatment of Brain abcess

Sx excision and drainage with a course of 6-8 wks of Abx follow through
CT guided needle aspiration

87

what is the most common Peripheral Nerve Entrapment syndrome

median nerve with carpal tunnel syndrome

88

what are the major functions of media nerve

Motor - Thumb opposition and thumb abduction

Sensory- Thumb, index, midddle, and lateral half of the ring finger.

89

What are the major Ulnar Nerve Functions

Motor - Flexor carpi ulnaris, flexor digitorum profundus, opponens digiti minimi, abductor digiti minimi, interossei muscles etc.

Sensory- Medial half of the hand, including small finger and medial half of the ring finger, both the palmar and dorsal sides

90

what is the disease known for compression of the median nerve at the wrist. it is the MC of the mononeuropathies with about a 14% lifetime prevalence

Carpal Tunnel Syndrome

91

What are the Etiology, epidemiology, and etc. of carpal tunnel

Can occur at any age but follows common bimodal distribution peak at early 50's and 75-84 years

Three times as common in women

Often seen with repetitive movements or vibrations - occupational and mechanic is common
Can be significantly debilitating, especially if severe and bilateral

92

what is pathophysiology of Carpal Tunnel Syndrome

Median nerve compression occurs due to increased pressure within the carpal tunnel, a passageway for the median nerve and 9 flexor tendons, covered by the Transverse Carpal Ligament

Tenosynovitis of the flexor tendons- one of the most common cause.

other causes of compression include fractures, mass lesions (like a synovial cyst), infection, pregnancy, etc.

93

Characteristic s/s of Carpal Tunnel Syndrome

Paresthesias (often painful)
distribution of the median nerve is classic.
Can develop weakness of thumb and thumb opposition
Severe cases have continual numbness and or atrophy of the thumb musculature.
Being woken in the night by painful paresthesias of the hand is very characteristic

94

Diagnostic approach to Carpal Tunnel Syndrome

Tinel's Sign may be positive over the transverse Carpal Ligament

Phalen's Sign can be positive with reproduction of the pt's symptoms while holding in wrist flexion

Electrodiagnostic studies (especially the nerve conduction study)

95

Not common but useful is the measurement of the diameter of the median nerve utilizing what?

Ultrasound

96

If a mass lesion is susspected cause of carpal tunnel syndrome what imaging can be used

MRI of the wrist

97

Management of Carpal Tunnel Syndrome Conservative measure

Reducing, eliminating, or modicying exacerbating activities. Wearing Wrist Splints (especially during sleep)
Local Corticosteroid injection - this is very benificial for some pts. although this needs to be performed by an experienced expert

98

how many weeks of conservative measurement should be attempted before sx referral is recommended to be made

2-7 wks

99

what are indications for surgical intervention

Significant motor deficit or NCS/EMG results revealing severe disease

100

what sx is utilized to fix carpal tunnel

Endoscopic and open decompression - surgeons choice

101

Cubital Tunnel Syndrome is what number of common mononeuropathy

Second most common

102

Cubital tunnel syndrome effects what nerve

Ulnar nerve

103

what are risk factors for Cubital tunnel syndrome

smoking, repetitive movements involve the elbow (such as occupational), or frequent and repetitive direct pressure on the elbow.

104

is cubital tunnel syndrome more likely to happen in men or women

4-5 times more common in women and a lifetime prevalence of less than 1%

105

Pathophysiology Ulnar nerve entrapment

Idopathic, due to active compression or nerve, or associated with ulnar nerve subluxation over the media epicondyle (with or without compression)

106

Which occupation is common to have ulnar nerve entrapment

Semi-Truck Drivers

107

Characteristic Signs and symptoms of cubital tunnel syndrome

Pt with will report paresthesias over the 4th and 5th fingers
Experience weakness of the hand, especially with grip strength
Certain movements of arm can sometimes make it worse
Can have positive Tinel's at the elbow.

108

What is the Diagnostic approach for Cubital tunnel syndrome

Spurling test and imaging can help rule out a C8 spinal nerve compression in the cervical spine

Electrodiagnosis (NCS / EMG) are diagnostic for ulnar nerve entrapment

Assess the strength of hands, including flexor muscles of the fingers

109

What is the Watenburg Sign and what are we testing for

Testing for ulnar deviation of the small finger with placment of the hands on a table

can show cubital tunnel syndrome

110

What is the proper name for claw hand that is seen with cubital Tunnel Syndrome

Duchenne Sign - inibility to hyperextend the joints of the ring and especially the small finger

111

what is the Froment sign and what is it used to assess

Flexion of the thumb is required for a pt to hold onto and pinch a piece of paper. Utilized to test for cubital tunnel syndrome

112

Management of cubital tunnel syndrome

Conservative therapy- may include PT, OT, activity modification, NSAIDs, sometimes steroid injections

113

when is surgery warranted for cubital tunnel syndrome

If motor weakness is present, or if the pt fails several wks of conservative therapy

114

What does sx intervention include fore cubital tunnel syndrome

Finding / following ulnar nerve and decompressing area of nerve compression

115

What are the two names fore the nerve running through the back of the knee that gives the LE's innervation

Peroneal Nerve or (Fibular Nerve)

116

motor and sensory function of the Peroneal Nerve

Peroneus longus and brevis, anterior tibialis, extensor hallucis longus, extenor digitrum longus etc.

Sensory- Each branch innervates a portion of the anterolateral shin/foot

117

What is the most common mononeuropathy of the lower leg

Peroneal Nerve Palsy

118

which occupation has higher rates of peroneal nerve palsy found

Dancers

119

what is the other name for peroneal nerve palsy

Fibular nerve Mononeuropathy of Palsy

120

Severe foot drop that is misdiagnosed as L4-5 HNP is a s/s of what

Peroneal Nerve Palsy

121

Toe has what in peroneal nerve palsy

Dorsiflexion and Extenosr hallucis Longus Weakness

122

Rule out the what with what for Peroneal nerve palsy

MRI

123

Diagnositc test of choic eo fre peroneal nere paslsy

NCS/EMG study

124

What is the orthosis that is used post

AFO- ankle foot orthosis

125

What are the different levels of Altered Mental Status

Anywhere form confused but awake to completely and persistently unresponsive

126

AMS autamatically trigges consult with

Neurology

127

top three causes of coma

Intoxication
Diabetic dysregulation
traumatic head injury

128

1st priority for management in any cause of unresponsiveness

Protect the pt's airway and breathing

129

Approach to pts with AMS

Stabilize
DIagnose
Manage

130

Causes of coma if in brainstem

Pontine Hemorrhage
Basilar Artery Occlusion
Central Pontine Myelinolysis
Brainstem hemorrhagic Cotntusion

131

Causes of Cerebellum Coma

Cerebellar Infarct
Cerebellar Hematoma
Cerebellar Abscess
Cerebellar Tumor

132

Acute Metabolic Endocrine Derangement

Hypoglycemia, Hyperglycemia, hyponatremia, hypernatremia, Addison's, hypercalcemia, acute hypothyroidism, Acute Panhypopituitarism
Acute Uremia, hyperbilirubinemia, Hypercapina