NR 603 WEEK 1 Questions and Answers
Verified 100% Correct
A 70-year-old woman is brought to your attention by her family because of the
slowly progressive gait disorder, the impairment of mental function, and urinary
incontinence. About 1 year ago, she started having weakness and tiredness in her
legs, followed by unsteadiness; her steps became shorter and shorter, and she also
experienced unexplained backward falls. She is becoming emotionally indifferent,
inattentive, and her actions and thinking have became "dull". Over the past month,
she has started having urinary urgency and involuntary leaking of urine. Besides
multivitamins and local application of the Timolol for glaucoma, she takes no other
medications; there are no other symptoms.
Question
What is most likely the best method of treating the patient's urinary problems?
ANSWER Choices
1 Antimuscarinic drug (Tolterodine)
2 Antibiotic (Sulfamethoxazole/trimethoprim)
3 Acetylcholinesterase inhibitor (Donepezil)
4 Ven - ANSWER -Ventriculoperitoneal shunt
Clinical triad of slowly progressive gait disorder, followed by impairment of
mental function and then sphincteric incontinence strongly suggests the presence
of normal-pressure hydrocephalus. Ventricular expansion is the cause of
symptoms, and surgical CSF shunting is the main treatment modality. The
potential benefit from surgery is usually evaluated by testing gait, cognition, and
micturition before and after CSF drainage.
Antimuscarinic Tolterodine is an antispasmodic that is used for symptomatic
treatment of urinary incontinence in patients with an overactive bladder (urge
incontinence). Antimuscarinic drugs are contraindicated in patients with glaucoma.
A urinary tract infection will probably manifest with a strong, persistent urge to
urinate, burning sensation when urinating, passing frequent, small amounts of urine
that has unusual smell and the appearance. Your patient has no such signs and
symptoms; therefore, in this case, antibiotics are not indicated.
,Donepezil is used to treat dementia, but in the case of normal-pressure
hydrocephalus, the problem is anatomic (the distortion of the periventricular limbic
system and frontal lobes), and the best treatment is probably surgical.
Kegel exercises can prevent or control urinary incontinence and other pelvic floor
problems in cases of pelvic sphincter weakness. However, pelvic sphincter
weakness will probably manifest as stress incontinence.
A 5-month-old male infant presents after a seizure involving all 4 limbs. His
mother tells you that he was born full term without any complications, and he was
well until 2 days ago when he developed a fever. He vomited multiple times
yesterday and was irritable. He has not had diarrhea or a cough. He was given
antipyretic medication for his fever. He has no known allergies. His immunizations
are up-to-date. His developmental milestones have been in accordance with his
age. On physical exam, his temperature is 102.7 F, and his pulse is 154/min; BP is
90/50 mmHg, and RR is 20/min. He is lethargic, pale, and focal neurological
deficits are present. His anterior fontanel is bulging. You suspect that he has
bacterial meningitis.
Question
After drawing blood samples for investigations, what is the most appropriate next
step?
ANSWER Choices
1 Intravenous phenytoin
2 Intravenous empirical antibiotics
3 MRI of the head
4 Lu - ANSWER -intravenous emiprical antibiotics
The infant in the vignette appears to have bacterial meningitis. The initial approach
to the patient should be the "ABCs." After assessing and stabilizing the patient's
airway and obtaining IV access, intravenous antibiotics should be given
immediately. As bacterial meningitis is associated with high morbidity and
mortality, prompt initiation of empirical antibiotics is crucial for better prognosis.
The choice of antibiotics is dependent on the patient's age and specific
predisposing conditions. Use of broad-spectrum cephalosporins, such as
ceftriaxone or cefotaxime with vancomycin, may be used in infants more than 1
month old. Ideally, serum glucose, blood culture, complete blood count, and serum
chemistries should be drawn when IV access is obtained; however, drawing labs
should not delay beginning antibiotics.
Intravenous glucose is necessary if the patient is found to be hypoglycemic;
bedside serum glucose is mandatory in any patient that presents with a seizure.
,Intravenous phenytoin and an MRI of the head might also be necessary for a
patient such as the one in the vignette, but would not emergently precede
antibiotics.
The diagnosis of bacterial meningitis rests on CSF examination performed after
lumbar puncture. However, LP is deferred in patients with evidence of increased
intracranial pressure, new onset seizure, cardiorespiratory compromise, or focal
neurological deficits. Antibiotics should be given, and CT scan of the head should
be performed. If CT scan is negative, LP can be performed.
A 12-year-old girl presents with a 3-day history of progressive dysarthria,
dysphagia, and weakness. The patient was well until 3 days prior to admission to
the hospital; at that time, she developed the onset and subsequent gradual
worsening of dysarthria. She attributed the dysarthria to a sore throat that she had
had about 2 weeks earlier. 3 days prior to admission, she also had the onset of mild
dysphagia; it mostly occurred with liquids. 24 hours prior to admission, she
developed weakness in both upper extremities, which increased and began to
involve the lower extremities. This limb weakness was neither worsened by
activity nor improved by rest. She also developed tingling in her toes 24 hours
prior to presentation. When she became unable to walk without assistance on the
day of admission, she decided to seek medical attention and was admitted to the
hospital.
Past medical history is significant for measles and - ANSWER -5 Her rapidly
evolving clinical course indicates a poor prognosis
This patient must be watched very closely for the very real possibility of
respiratory failure and the need for ventilatory support (2).
Mortality is expected to be less than 5% with good medical support (1).
With a demyelinating pattern on EMG, her prognosis is better. A consistent
indicator of residual muscle weakness is an EMG pattern of axonal damage, with
the more severe degrees of damage suggesting the worse prognosis (1).
About 85% of patients with GBS have a full functional recovery within a year;
however, some may be left with minor residuals such as areflexia on exam (2).
Between 5-10% of patients with Guillain-Barre have 1 or more relapses; these
cases are referred to as chronic inflammatory demyelinating peripheral neuropathy
(CIDP) (1).
, A 45-year-old African-American man with no significant past medical history
presents with a 1-hour history of left retroorbital headache. The headache was of a
sudden onset and began upon waking that morning. It is described as excruciating,
stabbing, sharp, and lancinating; it is rated as severe in intensity. He denies any
preceding infections, nausea, vomiting, photophobia, or osmophobia; he also
denies fever, chills, stiff neck, focal weakness, numbness, tingling, vision, hearing,
gait, or speech changes. He recalls a similar episode several months ago; it lasted
about a week, and it dissipated without complications.
His physical exam is remarkable for painful distress, lacrimation with conjunctival
injection, nasal congestion, rhinorrhea, left ocular miosis, and left forehead
diaphoretic flushing.
Question
What pharmacologic agent is the most beneficial for this patient at this time?
ANSWER Choices
1 Sumatrip - ANSWER -Sumatriptan
The correct response is sumatriptan.
This patient's most likely diagnosis is most likely a cluster headache.
Pharmacologic management of cluster headache may be divided into
abortive/symptomatic and preventive/prophylactic strategies. Abortive agents are
used to stop or reduce the severity of an acute attack, and include oxygen, triptans,
ergot alkaloids, and anesthetics. Inhalation of high-flow concentrated oxygen is
extremely effective for aborting attacks. 5-Hydroxytryptamine-1 (5-HT1) receptor
agonists, such as triptans or ergot alkaloids with metoclopramide, are often the first
line of treatment. Stimulation of 5-HT1 receptors produces a direct
vasoconstrictive effect and may abort the attack. Subcutaneous injection of
sumatriptan can be effective, in large part because of the rapidity of onset. Studies
have indicated that intranasal administration is more effective than placebo but not
as effective as injections.
Prophylactic agents are used to reduce the frequency and intensity of individual
headache exacerbations.
Preventive and prophylactic medications include calcium channel blockers, mood
stabilizers, and anticonvulsants. Verpamil is the most effective calcium channel
blocker for prophylaxis. It inhibits calcium ions from entering slow channels,
select voltage-sensitive areas, or vascular smooth muscle, thereby producing
Verified 100% Correct
A 70-year-old woman is brought to your attention by her family because of the
slowly progressive gait disorder, the impairment of mental function, and urinary
incontinence. About 1 year ago, she started having weakness and tiredness in her
legs, followed by unsteadiness; her steps became shorter and shorter, and she also
experienced unexplained backward falls. She is becoming emotionally indifferent,
inattentive, and her actions and thinking have became "dull". Over the past month,
she has started having urinary urgency and involuntary leaking of urine. Besides
multivitamins and local application of the Timolol for glaucoma, she takes no other
medications; there are no other symptoms.
Question
What is most likely the best method of treating the patient's urinary problems?
ANSWER Choices
1 Antimuscarinic drug (Tolterodine)
2 Antibiotic (Sulfamethoxazole/trimethoprim)
3 Acetylcholinesterase inhibitor (Donepezil)
4 Ven - ANSWER -Ventriculoperitoneal shunt
Clinical triad of slowly progressive gait disorder, followed by impairment of
mental function and then sphincteric incontinence strongly suggests the presence
of normal-pressure hydrocephalus. Ventricular expansion is the cause of
symptoms, and surgical CSF shunting is the main treatment modality. The
potential benefit from surgery is usually evaluated by testing gait, cognition, and
micturition before and after CSF drainage.
Antimuscarinic Tolterodine is an antispasmodic that is used for symptomatic
treatment of urinary incontinence in patients with an overactive bladder (urge
incontinence). Antimuscarinic drugs are contraindicated in patients with glaucoma.
A urinary tract infection will probably manifest with a strong, persistent urge to
urinate, burning sensation when urinating, passing frequent, small amounts of urine
that has unusual smell and the appearance. Your patient has no such signs and
symptoms; therefore, in this case, antibiotics are not indicated.
,Donepezil is used to treat dementia, but in the case of normal-pressure
hydrocephalus, the problem is anatomic (the distortion of the periventricular limbic
system and frontal lobes), and the best treatment is probably surgical.
Kegel exercises can prevent or control urinary incontinence and other pelvic floor
problems in cases of pelvic sphincter weakness. However, pelvic sphincter
weakness will probably manifest as stress incontinence.
A 5-month-old male infant presents after a seizure involving all 4 limbs. His
mother tells you that he was born full term without any complications, and he was
well until 2 days ago when he developed a fever. He vomited multiple times
yesterday and was irritable. He has not had diarrhea or a cough. He was given
antipyretic medication for his fever. He has no known allergies. His immunizations
are up-to-date. His developmental milestones have been in accordance with his
age. On physical exam, his temperature is 102.7 F, and his pulse is 154/min; BP is
90/50 mmHg, and RR is 20/min. He is lethargic, pale, and focal neurological
deficits are present. His anterior fontanel is bulging. You suspect that he has
bacterial meningitis.
Question
After drawing blood samples for investigations, what is the most appropriate next
step?
ANSWER Choices
1 Intravenous phenytoin
2 Intravenous empirical antibiotics
3 MRI of the head
4 Lu - ANSWER -intravenous emiprical antibiotics
The infant in the vignette appears to have bacterial meningitis. The initial approach
to the patient should be the "ABCs." After assessing and stabilizing the patient's
airway and obtaining IV access, intravenous antibiotics should be given
immediately. As bacterial meningitis is associated with high morbidity and
mortality, prompt initiation of empirical antibiotics is crucial for better prognosis.
The choice of antibiotics is dependent on the patient's age and specific
predisposing conditions. Use of broad-spectrum cephalosporins, such as
ceftriaxone or cefotaxime with vancomycin, may be used in infants more than 1
month old. Ideally, serum glucose, blood culture, complete blood count, and serum
chemistries should be drawn when IV access is obtained; however, drawing labs
should not delay beginning antibiotics.
Intravenous glucose is necessary if the patient is found to be hypoglycemic;
bedside serum glucose is mandatory in any patient that presents with a seizure.
,Intravenous phenytoin and an MRI of the head might also be necessary for a
patient such as the one in the vignette, but would not emergently precede
antibiotics.
The diagnosis of bacterial meningitis rests on CSF examination performed after
lumbar puncture. However, LP is deferred in patients with evidence of increased
intracranial pressure, new onset seizure, cardiorespiratory compromise, or focal
neurological deficits. Antibiotics should be given, and CT scan of the head should
be performed. If CT scan is negative, LP can be performed.
A 12-year-old girl presents with a 3-day history of progressive dysarthria,
dysphagia, and weakness. The patient was well until 3 days prior to admission to
the hospital; at that time, she developed the onset and subsequent gradual
worsening of dysarthria. She attributed the dysarthria to a sore throat that she had
had about 2 weeks earlier. 3 days prior to admission, she also had the onset of mild
dysphagia; it mostly occurred with liquids. 24 hours prior to admission, she
developed weakness in both upper extremities, which increased and began to
involve the lower extremities. This limb weakness was neither worsened by
activity nor improved by rest. She also developed tingling in her toes 24 hours
prior to presentation. When she became unable to walk without assistance on the
day of admission, she decided to seek medical attention and was admitted to the
hospital.
Past medical history is significant for measles and - ANSWER -5 Her rapidly
evolving clinical course indicates a poor prognosis
This patient must be watched very closely for the very real possibility of
respiratory failure and the need for ventilatory support (2).
Mortality is expected to be less than 5% with good medical support (1).
With a demyelinating pattern on EMG, her prognosis is better. A consistent
indicator of residual muscle weakness is an EMG pattern of axonal damage, with
the more severe degrees of damage suggesting the worse prognosis (1).
About 85% of patients with GBS have a full functional recovery within a year;
however, some may be left with minor residuals such as areflexia on exam (2).
Between 5-10% of patients with Guillain-Barre have 1 or more relapses; these
cases are referred to as chronic inflammatory demyelinating peripheral neuropathy
(CIDP) (1).
, A 45-year-old African-American man with no significant past medical history
presents with a 1-hour history of left retroorbital headache. The headache was of a
sudden onset and began upon waking that morning. It is described as excruciating,
stabbing, sharp, and lancinating; it is rated as severe in intensity. He denies any
preceding infections, nausea, vomiting, photophobia, or osmophobia; he also
denies fever, chills, stiff neck, focal weakness, numbness, tingling, vision, hearing,
gait, or speech changes. He recalls a similar episode several months ago; it lasted
about a week, and it dissipated without complications.
His physical exam is remarkable for painful distress, lacrimation with conjunctival
injection, nasal congestion, rhinorrhea, left ocular miosis, and left forehead
diaphoretic flushing.
Question
What pharmacologic agent is the most beneficial for this patient at this time?
ANSWER Choices
1 Sumatrip - ANSWER -Sumatriptan
The correct response is sumatriptan.
This patient's most likely diagnosis is most likely a cluster headache.
Pharmacologic management of cluster headache may be divided into
abortive/symptomatic and preventive/prophylactic strategies. Abortive agents are
used to stop or reduce the severity of an acute attack, and include oxygen, triptans,
ergot alkaloids, and anesthetics. Inhalation of high-flow concentrated oxygen is
extremely effective for aborting attacks. 5-Hydroxytryptamine-1 (5-HT1) receptor
agonists, such as triptans or ergot alkaloids with metoclopramide, are often the first
line of treatment. Stimulation of 5-HT1 receptors produces a direct
vasoconstrictive effect and may abort the attack. Subcutaneous injection of
sumatriptan can be effective, in large part because of the rapidity of onset. Studies
have indicated that intranasal administration is more effective than placebo but not
as effective as injections.
Prophylactic agents are used to reduce the frequency and intensity of individual
headache exacerbations.
Preventive and prophylactic medications include calcium channel blockers, mood
stabilizers, and anticonvulsants. Verpamil is the most effective calcium channel
blocker for prophylaxis. It inhibits calcium ions from entering slow channels,
select voltage-sensitive areas, or vascular smooth muscle, thereby producing
