Answer and Explanation 5

5.  Choice B it the correct answer. The Trigeminal nerve is responsible the corneal reflex.  The optic nerve is responsible for actually seeing the object touching the cornea, but there is no motor component.  The facial nerve is responsible for the features of facial expression (smile, frown, wrinkle forehead, and puff cheeks out).  The occulomotor nerve is responsible for direct and consensual pupillary light response and some of the extra-occular movements.

Question 5

5.  Which cranial nerve is responsible for the corneal reflex?

A.  VII (Facial)

B. V (Trigeminal)

C.  III (Occulomotor)

D.  II (Optic Nerve)

Answer and Explanation 4

4.  Choice B is the correct answer.  This patient has bacterial meningitis.  The current standard of care is to start the patient on Rocephin 2 grams, Vancomycin 1 gram, and Acyclovir IV until the cultures come back or gram stain is available.  Patients with viral meningitis typically have low WBC and normal glucose.  Patients with viral meningitis only need to be admitted for symptomatic management or if they have comorbid disorders. These results are definitely not normal.  Technically any WBC over 5 in the CSF is considered abnormal.

Question 4

4.  Your patient is an 38 year old male that presents with a fever of 102, headache, neck pain and stiffness.  He has had nausea and vomiting.  You decide to do a spinal tap and the results are as follows:
WBC 2500, RBC 2, Glucose 12 (low), Protein high.   The patients culture and gram stain is pending.  Based upon this data, which of the following is the best management option?

A.  Admit the patient to the hospital for symptomatic treatment.

B.  Give the patient 2 grams or Rocephin IV, 1 gram of Vancomycin, and Acyclovir IV and admit the patient to the hospital

C.  Start the patient on Acyclovir empirically and admit the patient to the hospital.

D.  Discharge the patient home, these spinal results are normal

Answer and Explanation 3

3.  C is the correct answer.  This patient has a large left sided subarachnoid hemorrhage with a midline shift.  She needs her Coumadin reversed as soon as possible.  Protamine is the reversal agent for heparin not Coumadin.  Patients with subdural hematoma have the bleeding around the outside of the brain not in the parachemyma.  This patient does not have a visible brain mass on CT scan.  It is not uncommon for patients to bleed into the mass but they are usually more circumscribed and not so irregular.

Question 3

3.  Your patient is a 83 year old female who presents with a headache and the CT scan below.  She is also on Coumadin.  Based upon this data, which of the following is the best management plan?

A.  Stat neurosurgery consult, give the patient protamine sulfate, and admit to the hospital

B.  Consult trauma surgery for the patients subdural hematoma

C.  Given the patient fresh frozen plasma, vitamin k, consult neurosurgery and admit to the hospital.

D.  Consult oncology for the patients brain mass

Answer and Explanation 2

2.  Choice A is the correct answer.  Patients with unilateral weakness or sensory complaints have the lesion in the contralateral cerebral hemisphere.  A brain stem infarct would cause contralateral weakness or sensory complaints on the contralateral side, it would cause ipsilateral weakness or sensory complaints in the pace.  Occipital CVA's typically cause hemivisual loss to the contralateral from the contralateral hemisphere.  

Question 2

2.  Your patient is an 83 year old female who presents with right arm paralysis that started when she woke up 2 weeks ago.  She has a history of hyperlipidemia, hypertension, and smoking.  Her accucheck is 94.  Based on her physical exam, where would you expect to find the area of her likely CVA on CT scan?

A.  Left cerebral hemisphere

B.  Brain Stem

C.  Occipital area of her brain

D.  Right cerebral hemisphere

Answer and Explanation 1

1.  B is the correct answer.  This patient is presenting with a history concerning for subarachnoid hemorrhage (SAH).  CT scans of the head without contrast are 90-95% sensitive for detecting SAH.  The accepted standard of care is to offer the patient in this situation a lumbar puncture.  Choice D may sound like a good option; however, if a bleed or leaking aneurysm is detected on the study, the provider may have some answering to do.  Especially if there is a delay between the patient encounter, and getting the results of the study.  This should be treated as a seconds to minutes emergency.  An EEG would not be helpful at this point.  Choice A would be plausible if the patient refused admission and refused the spinal tap.

Question 1

1.  Your patient is a 45 year old female that presents with a sudden onset of right sided headache.  She has photophobia, nausea, and vomiting.  This patient has no prior history of headaches.  Her vital signs are BP 124/68, Pulse 89, RR-14, and Temp 98.8.  Her CT scan of her head without contrast is negative.  You have given her Reglan 10 mg IV, Ativan 1 mg IV, and 1 liter of normal saline.  When you go back to reassess her, her headache is now gone.  Based upon the above information, what is the best management plan?

A. Discharge the patient home with a driver, with neurology follow up

B.  Obtain a Lumbar Puncture

C.  Get an STAT EEG on the patient

D.  Admit the patient to the hospital and try to get an MRA of the head in the morning