NR 603 WEEK 1 Questions and Answers
Verified 100% Correct
A 1-year-old boy presents with increasing lethargy. He is barely responsive, and
his parents deny any trauma or injury. What is the most common cause of
nontraumatic altered levels of consciousness?
ANSWER Choices
1 Seizure disorder
2 Diabetic ketoacidosis
3 Inborn errors of metabolism
4 Toxic ingestion
5 Infection
ANS:5 - ANSWER -infection
Awareness of self and the surrounding environment or consciousness may be
altered into different abnormal states of consciousness. Consciousness can shift
from loss of clear thinking or confusion, usually accompanied by disorientation, to
delirium, a succession of confused and unconnected ideas manifested in children as
extreme mental and motor excitement, to lethargy, a profound type of slumber
where movement or speech is limited, to stupor or deep sleep where arousal is
achieved only by repeated vigorous stimuli, finally to coma, unresponsiveness to
even painful stimuli. Non-traumatic coma is most common in infants and toddlers
with another smaller peak of occurrence in adolescence. The most common cause
of non-traumatic altered level of consciousness in children is infection of either the
brain (encephalitis), meninges (meningitis), or both; infections account for more
than 1/3 of cases.
Prolonged seizures, anticonvulsive therapy, and postictal states can also lead to
altered levels of consciousness.
The most common metabolic cause of alteration of consciousness is diabetic
ketoacidosis, which can occur at any age, but is most common in adolescence.
Caused by severe insulin deficiency, hyperglycemia and ketogenesis lead initially
to polyuria, polydipsia, hyperpnea, vomiting, and abdominal pain. As the process
progresses, hyperosmolar dehydration and acid/base and electrolyte disturbances
occur. Advanced stages alter level of consciousness and can lead to coma.
,Alterations of consciousness due to inborn errors of metabolism that present with
electrolyte and glucose abnormalities typically present in infancy. The availability
of gluconeogenic precursors or the functions of the enzymes required for
production of hepatic glucose are affected. Metabolic defects causing
hypoglycemia include glycogen storage d
A 44-year-old man starts to notice that his eyelids are drooping. Some time
afterwards, his jaw becomes weak. He has difficulty swallowing and also
experiences weakness in his limbs. He is quite embarrassed when he eats because
he must use his hand to help support his jaw. His weakness gets progressively
worse. Finally, he seeks medical attention. His physical examination demonstrates
the weakness in his limbs; however, no sensory defects are present. A Tensilon test
is done and is positive. His doctor is concerned about an associated malignancy.
What is the underlying pathology of this disease?
ANSWER Choices
1 Inhibition of acetylcholine release
2 Blockage of the sodium channels
3 Demyelination
4 Subacute combined degeneration of the spinal cord
5 Antibodies to the acetylcholine receptor
ANS: 5 - ANSWER -5 Antibodies to the acetylcholine receptor
Antibodies directed towards the acetylcholine receptor at the neuromuscular
junction are seen with myasthenia gravis.
This man has myasthenia gravis. Ocular muscle weakness, ptosis, dysphagia, and
limb weakness can all be seen with myasthenia gravis. When the initial symptom is
ocular weakness, Eaton Lambert Syndrome is extremely unlikely. Eaton Lambert
Syndrome tends to not involve the extra-ocular muscles or the muscles involving
chewing, swallowing, or speech.
The Tensilon test is used in the diagnosis of myasthenia gravis. The Tensilon test
consists of the administration of edrophonium. Edrophonium is a quick acting
anticholinesterase.
Thymic tumors are associated with myasthenia gravis. Thymic tumors are also
referred to as thymomas. Approximately 10 - 15% of patients with myasthenia
gravis have an associated thymoma. The majority of patients with myasthenia
gravis have hyperplasia of their thymus.
,Botulinum toxin inhibits acetylcholine release. The site of action is at the
neuromuscular junction. Botulinum toxin is an enterotoxin produced by
Clostridium botulinum. Botulism can result from incorrectly canned foods.
Tetrodotoxin is a toxin produced by puffer fish. The sodium channels are blocked
by tetrodotoxin. The blockage of the sodium channels interferes with the inflow of
sodium. As a result, the propagation of nerve and muscle action potentials is
affected.
Demyelination refers to the loss of myelin around the axon. Several disorders
result in demyelination. An example of a demyelinating disease is multiple
sclerosis.
Subacute combined degeneration of the spinal cord is also called combined
systems disease. Subacute combined degeneration of the spinal cord is a
neuropathy secondary to B12 deficiency. It is seen in patients with pernicious
anemia, especially p
A 74-year-old man presents after his wife witnessed him grab his head in pain and
fall to the floor. He has not regained consciousness. His current blood pressure is
150/96 mm Hg, and his heart rate is 65 bpm. Emergent head CT shows a
subarachnoid hemorrhage.
Question
In addition to life saving interventions, what prescription medication will most
benefit this patient at this time?
ANSWER Choices
1 Furosemide (loop diuretic)
2 Prednisone (glucocorticoid)
3 Tranexamic acid (antifibrinolytic agent)
4 Labetolol (beta blocker)
5 Nimodipine (calcium channel blocker)
ANS: 5 - ANSWER -Nimodipine (CCB)
Nimodipine, a calcium channel blocker, has been shown to improve outcomes in
patients following aneurysmal SAH. The mechanism of action is thought to be
prevention of ischemia. Glucocorticoids (e.g., prednisone) are often utilized in
patients with SAH because they offer symptomatic relief of headache and neck
pain, but they have not been proved to decrease cerebral edema. Antifibrinolytic
agents (e.g., Tranexamic acid) can be utilized in patients with a diagnosed
, aneurysm who cannot undergo directed treatment, but they are not routinely used
following aneurysmal rupture. Labetalol (a beta blocker) may be utilized to treat
elevated BP, but it must be used with caution because it can also decrease cerebral
perfusion. Diuretics (e.g., furosemide) have no identified role in the treatment of
aneurysmal SAH.
A 37-year-old woman presents to her GP surgery with a history of right-sided
facial weakness and peri-auricular discomfort since she awoke this morning. She is
afebrile.
Question
What is the most likely diagnosis?
ANSWER Choices
1 Trigeminal neuralgia
2 Bell's Palsy
3 Multiple sclerosis
4 Myasthenia gravis
5 Primary lateral sclerosis
ANS: 2 - ANSWER -Bell's Palsy
Explanation The correct ANSWER is Bell's palsy, which is a condition typically
with sudden onset that affects the facial nerve, causing unilateral facial weakness.
Trigeminal neuralgia presents with sharp pain on one side of the mouth that
radiates to the ipsilateral ear, eye, or nostril.
Multiple sclerosis is a demyelinating disorder, causing a multitude of symptoms
that typically include diplopia or blurred vision early on, then an insidious onset of
progressive weakness, numbness, and/or tingling in the extremities.
Myasthenia gravis commonly presents with ptosis and diplopia, as well as
difficulty swallowing, fatigue, and muscle weakness.
Primary lateral sclerosis is an upper motor neuron disease that causes limb
weakness, stiffness, and fasciculations.
A 62-year-old man presents with vision problems and difficulty swallowing. Over
the last week, he has had a constellation of symptoms; they began with numbness
and tingling in his feet and progressed to weakness that now affects both lower and
upper extremities. Within the last day, he has started to notice difficulty
swallowing and double vision. He also feels it is difficult for him to take a big
Verified 100% Correct
A 1-year-old boy presents with increasing lethargy. He is barely responsive, and
his parents deny any trauma or injury. What is the most common cause of
nontraumatic altered levels of consciousness?
ANSWER Choices
1 Seizure disorder
2 Diabetic ketoacidosis
3 Inborn errors of metabolism
4 Toxic ingestion
5 Infection
ANS:5 - ANSWER -infection
Awareness of self and the surrounding environment or consciousness may be
altered into different abnormal states of consciousness. Consciousness can shift
from loss of clear thinking or confusion, usually accompanied by disorientation, to
delirium, a succession of confused and unconnected ideas manifested in children as
extreme mental and motor excitement, to lethargy, a profound type of slumber
where movement or speech is limited, to stupor or deep sleep where arousal is
achieved only by repeated vigorous stimuli, finally to coma, unresponsiveness to
even painful stimuli. Non-traumatic coma is most common in infants and toddlers
with another smaller peak of occurrence in adolescence. The most common cause
of non-traumatic altered level of consciousness in children is infection of either the
brain (encephalitis), meninges (meningitis), or both; infections account for more
than 1/3 of cases.
Prolonged seizures, anticonvulsive therapy, and postictal states can also lead to
altered levels of consciousness.
The most common metabolic cause of alteration of consciousness is diabetic
ketoacidosis, which can occur at any age, but is most common in adolescence.
Caused by severe insulin deficiency, hyperglycemia and ketogenesis lead initially
to polyuria, polydipsia, hyperpnea, vomiting, and abdominal pain. As the process
progresses, hyperosmolar dehydration and acid/base and electrolyte disturbances
occur. Advanced stages alter level of consciousness and can lead to coma.
,Alterations of consciousness due to inborn errors of metabolism that present with
electrolyte and glucose abnormalities typically present in infancy. The availability
of gluconeogenic precursors or the functions of the enzymes required for
production of hepatic glucose are affected. Metabolic defects causing
hypoglycemia include glycogen storage d
A 44-year-old man starts to notice that his eyelids are drooping. Some time
afterwards, his jaw becomes weak. He has difficulty swallowing and also
experiences weakness in his limbs. He is quite embarrassed when he eats because
he must use his hand to help support his jaw. His weakness gets progressively
worse. Finally, he seeks medical attention. His physical examination demonstrates
the weakness in his limbs; however, no sensory defects are present. A Tensilon test
is done and is positive. His doctor is concerned about an associated malignancy.
What is the underlying pathology of this disease?
ANSWER Choices
1 Inhibition of acetylcholine release
2 Blockage of the sodium channels
3 Demyelination
4 Subacute combined degeneration of the spinal cord
5 Antibodies to the acetylcholine receptor
ANS: 5 - ANSWER -5 Antibodies to the acetylcholine receptor
Antibodies directed towards the acetylcholine receptor at the neuromuscular
junction are seen with myasthenia gravis.
This man has myasthenia gravis. Ocular muscle weakness, ptosis, dysphagia, and
limb weakness can all be seen with myasthenia gravis. When the initial symptom is
ocular weakness, Eaton Lambert Syndrome is extremely unlikely. Eaton Lambert
Syndrome tends to not involve the extra-ocular muscles or the muscles involving
chewing, swallowing, or speech.
The Tensilon test is used in the diagnosis of myasthenia gravis. The Tensilon test
consists of the administration of edrophonium. Edrophonium is a quick acting
anticholinesterase.
Thymic tumors are associated with myasthenia gravis. Thymic tumors are also
referred to as thymomas. Approximately 10 - 15% of patients with myasthenia
gravis have an associated thymoma. The majority of patients with myasthenia
gravis have hyperplasia of their thymus.
,Botulinum toxin inhibits acetylcholine release. The site of action is at the
neuromuscular junction. Botulinum toxin is an enterotoxin produced by
Clostridium botulinum. Botulism can result from incorrectly canned foods.
Tetrodotoxin is a toxin produced by puffer fish. The sodium channels are blocked
by tetrodotoxin. The blockage of the sodium channels interferes with the inflow of
sodium. As a result, the propagation of nerve and muscle action potentials is
affected.
Demyelination refers to the loss of myelin around the axon. Several disorders
result in demyelination. An example of a demyelinating disease is multiple
sclerosis.
Subacute combined degeneration of the spinal cord is also called combined
systems disease. Subacute combined degeneration of the spinal cord is a
neuropathy secondary to B12 deficiency. It is seen in patients with pernicious
anemia, especially p
A 74-year-old man presents after his wife witnessed him grab his head in pain and
fall to the floor. He has not regained consciousness. His current blood pressure is
150/96 mm Hg, and his heart rate is 65 bpm. Emergent head CT shows a
subarachnoid hemorrhage.
Question
In addition to life saving interventions, what prescription medication will most
benefit this patient at this time?
ANSWER Choices
1 Furosemide (loop diuretic)
2 Prednisone (glucocorticoid)
3 Tranexamic acid (antifibrinolytic agent)
4 Labetolol (beta blocker)
5 Nimodipine (calcium channel blocker)
ANS: 5 - ANSWER -Nimodipine (CCB)
Nimodipine, a calcium channel blocker, has been shown to improve outcomes in
patients following aneurysmal SAH. The mechanism of action is thought to be
prevention of ischemia. Glucocorticoids (e.g., prednisone) are often utilized in
patients with SAH because they offer symptomatic relief of headache and neck
pain, but they have not been proved to decrease cerebral edema. Antifibrinolytic
agents (e.g., Tranexamic acid) can be utilized in patients with a diagnosed
, aneurysm who cannot undergo directed treatment, but they are not routinely used
following aneurysmal rupture. Labetalol (a beta blocker) may be utilized to treat
elevated BP, but it must be used with caution because it can also decrease cerebral
perfusion. Diuretics (e.g., furosemide) have no identified role in the treatment of
aneurysmal SAH.
A 37-year-old woman presents to her GP surgery with a history of right-sided
facial weakness and peri-auricular discomfort since she awoke this morning. She is
afebrile.
Question
What is the most likely diagnosis?
ANSWER Choices
1 Trigeminal neuralgia
2 Bell's Palsy
3 Multiple sclerosis
4 Myasthenia gravis
5 Primary lateral sclerosis
ANS: 2 - ANSWER -Bell's Palsy
Explanation The correct ANSWER is Bell's palsy, which is a condition typically
with sudden onset that affects the facial nerve, causing unilateral facial weakness.
Trigeminal neuralgia presents with sharp pain on one side of the mouth that
radiates to the ipsilateral ear, eye, or nostril.
Multiple sclerosis is a demyelinating disorder, causing a multitude of symptoms
that typically include diplopia or blurred vision early on, then an insidious onset of
progressive weakness, numbness, and/or tingling in the extremities.
Myasthenia gravis commonly presents with ptosis and diplopia, as well as
difficulty swallowing, fatigue, and muscle weakness.
Primary lateral sclerosis is an upper motor neuron disease that causes limb
weakness, stiffness, and fasciculations.
A 62-year-old man presents with vision problems and difficulty swallowing. Over
the last week, he has had a constellation of symptoms; they began with numbness
and tingling in his feet and progressed to weakness that now affects both lower and
upper extremities. Within the last day, he has started to notice difficulty
swallowing and double vision. He also feels it is difficult for him to take a big
