NR 603 WEEK 1
A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on
the windshield. He complains of neck pain and severe burning in his shoulders and
arms. His physical examination reveals weakness of his upper extremities. What type of
spinal cord injury does this patient have?
A anterior cord syndrome
B central cord syndrome
C Brown-Séquard syndrome
D complete cord transection
E cauda equina syndrome
ANS: B - ANSWER-Central Cord Syndrome
the central cord syndrome involves loss of motor function that is more severe in the
upper extremities than in the lower extremities, and is more severe in the hands. There
is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome
presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with
preservation of posterior column function. Brown-Séquard syndrome consists of
weakness and loss of posterior column function on one side of the body distal to the
lesion with contralateral loss of lateral spinothalamic function one to two levels below
the lesion. Complete cord transection would affect motor and sensory function distal to
the lesion. Cauda equina syndrome typically presents as low back pain with
radiculopathy.
,A 37-year-old man fell from a ladder as he finished hanging the Christmas lights on his
house. The right side of his head hit the alley cement, and he lost consciousness for
about 1 minute; he woke up with a headache, but he had no other complaints. A few
hours later, the patient is brought to the emergency room by his neighbor because of
an intense headache, confusion, and left hand hemiparesis. On examination, the
patient has a bruise located over the right temporal region, mydriasis, and right
deviation of the right eye, papilledema, and left extensor plantar response. An
emergency CT scan of the head without contrast reveals a lens-shaped hyper-density
under the right temporal bone with mass effect and edema. What is the most likely
diagnosis?
Answer Choices
1 Epidural hematoma
2 Subdural hematoma
3 Subarachnoid hemorrhage
4 Intracerebral parenchymal hemorrhage
5 Acute meningitis
ANS: 1 - ANSWER-Epidural Hematoma
Epidural hematoma most often results from a traumatic tear of the middle meningeal
artery. Although a lucid interval ranging from minutes to hours followed by altered
mental status and focal deficits is typical for epidural hematoma, this clinical picture is
only encountered in up to 1/3 of the patients. The collection of blood between the skull
and dura mater causes an evident mass effect with ophthalmic nerve palsy and the
contralateral hemiparesis. Surgical evacuation of the clot via burr holes is the
treatment of choice.
Subdural hematoma results from a traumatic rupture of the bridging veins that connect
,the cerebrum to the venous sinuses within the dura. This venous hemorrhage will
result in a gradual increase of the hematoma, with a progressive clinical picture over
days or weeks. The CT scan will show a concave, crescent-shaped hyper-density
compared to the convex, lens-shaped hyper-density in epidural hematoma.
Subarachnoid hemorrhage is the result of an aneurysm rupture; the most common is
the congenital berry aneurysm. The clinical picture is of a sudden, severe headache
with meningeal irritation. A CT scan will show blood in the subarachnoid space, and a
lumbar puncture will reveal xanthochromia CSF.
Intracerebral parenchymal hemorrhage is most likely caused by hypertension
complicated with Charcot-Bouchard aneurysms. The blood accumulates into the brain
substance and most commonly involves the basal ganglia.
Acute meningitis is not associated with trauma. Fever and signs of meningeal irritation
dominate the clinical picture. Lumbar puncture, indicated if there are no focal
neurological signs on clinical examination, will be the diagnostic procedure. The CT scan
of the patient presented in this case is characteristic for epidural hematoma, and there
is no indication for a lumbar punctu
A 31-year-old woman presents with a purpural rash covering her arms, legs, and
abdomen. She also has fever, chills, nausea, abdominal tenderness, tachycardia, and
generalized myalgias. Prior to the development of the rash, the patient noted that she
had a headache, cough, and sore throat. Laboratory studies were positive for Gram-
negative diplococci in the blood, along with thrombocytopenia and an elevation in
PMNs. Urinalysis showed blood, protein, and casts. Vital signs are as follows: PB 92/66,
P 96, RR 14, T 39. The patient denies any foreign travel and does not have any sick
contacts. However, she does work part time as a nurse in a local hospital.
Question
, The patient is diagnosed with Meningococcemia; she is admitted to the hospital and
placed in respiratory isolation. What major course of therapy should this patient
receive?
Answer Choices
1 Steroids
2 Supportive care
3 Antibiotics
4 Transfusion
5 Bacterici - ANSWER-Antibiotics
Antibiotics are the treatment of choice for meningococcemia. The preferred drug for
active infection is penicillin G. For those allergic to penicillin, chloramphenicol and
cephalosporins (ie, cefotaxime, cefuroxime) may be used as alternatives.
Patients will also receive supportive care, but antibiotic therapy must be initiated
quickly if the patient is to survive. Intensive care placement may be necessary if organ
failure is imminent. Ventilatory support, inotropic support, and IV fluids are necessary
in some. If adrenal insufficiency occurs, corticosteroid replacement may be considered.
A central venous line helps to provide large amounts of volume expanders and
inotropic medications for adequate tissue perfusion.
Steroids have not been shown to play a major role in the treatment of
meningococcemia. However, they have been used in addition to antibiotic therapy. In
the case of adrenal insufficiency, for example, steroid replacement has been shown to
be beneficial.
Transfusion does not generally play a major role in treatment. If the patient suffers
A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on
the windshield. He complains of neck pain and severe burning in his shoulders and
arms. His physical examination reveals weakness of his upper extremities. What type of
spinal cord injury does this patient have?
A anterior cord syndrome
B central cord syndrome
C Brown-Séquard syndrome
D complete cord transection
E cauda equina syndrome
ANS: B - ANSWER-Central Cord Syndrome
the central cord syndrome involves loss of motor function that is more severe in the
upper extremities than in the lower extremities, and is more severe in the hands. There
is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome
presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with
preservation of posterior column function. Brown-Séquard syndrome consists of
weakness and loss of posterior column function on one side of the body distal to the
lesion with contralateral loss of lateral spinothalamic function one to two levels below
the lesion. Complete cord transection would affect motor and sensory function distal to
the lesion. Cauda equina syndrome typically presents as low back pain with
radiculopathy.
,A 37-year-old man fell from a ladder as he finished hanging the Christmas lights on his
house. The right side of his head hit the alley cement, and he lost consciousness for
about 1 minute; he woke up with a headache, but he had no other complaints. A few
hours later, the patient is brought to the emergency room by his neighbor because of
an intense headache, confusion, and left hand hemiparesis. On examination, the
patient has a bruise located over the right temporal region, mydriasis, and right
deviation of the right eye, papilledema, and left extensor plantar response. An
emergency CT scan of the head without contrast reveals a lens-shaped hyper-density
under the right temporal bone with mass effect and edema. What is the most likely
diagnosis?
Answer Choices
1 Epidural hematoma
2 Subdural hematoma
3 Subarachnoid hemorrhage
4 Intracerebral parenchymal hemorrhage
5 Acute meningitis
ANS: 1 - ANSWER-Epidural Hematoma
Epidural hematoma most often results from a traumatic tear of the middle meningeal
artery. Although a lucid interval ranging from minutes to hours followed by altered
mental status and focal deficits is typical for epidural hematoma, this clinical picture is
only encountered in up to 1/3 of the patients. The collection of blood between the skull
and dura mater causes an evident mass effect with ophthalmic nerve palsy and the
contralateral hemiparesis. Surgical evacuation of the clot via burr holes is the
treatment of choice.
Subdural hematoma results from a traumatic rupture of the bridging veins that connect
,the cerebrum to the venous sinuses within the dura. This venous hemorrhage will
result in a gradual increase of the hematoma, with a progressive clinical picture over
days or weeks. The CT scan will show a concave, crescent-shaped hyper-density
compared to the convex, lens-shaped hyper-density in epidural hematoma.
Subarachnoid hemorrhage is the result of an aneurysm rupture; the most common is
the congenital berry aneurysm. The clinical picture is of a sudden, severe headache
with meningeal irritation. A CT scan will show blood in the subarachnoid space, and a
lumbar puncture will reveal xanthochromia CSF.
Intracerebral parenchymal hemorrhage is most likely caused by hypertension
complicated with Charcot-Bouchard aneurysms. The blood accumulates into the brain
substance and most commonly involves the basal ganglia.
Acute meningitis is not associated with trauma. Fever and signs of meningeal irritation
dominate the clinical picture. Lumbar puncture, indicated if there are no focal
neurological signs on clinical examination, will be the diagnostic procedure. The CT scan
of the patient presented in this case is characteristic for epidural hematoma, and there
is no indication for a lumbar punctu
A 31-year-old woman presents with a purpural rash covering her arms, legs, and
abdomen. She also has fever, chills, nausea, abdominal tenderness, tachycardia, and
generalized myalgias. Prior to the development of the rash, the patient noted that she
had a headache, cough, and sore throat. Laboratory studies were positive for Gram-
negative diplococci in the blood, along with thrombocytopenia and an elevation in
PMNs. Urinalysis showed blood, protein, and casts. Vital signs are as follows: PB 92/66,
P 96, RR 14, T 39. The patient denies any foreign travel and does not have any sick
contacts. However, she does work part time as a nurse in a local hospital.
Question
, The patient is diagnosed with Meningococcemia; she is admitted to the hospital and
placed in respiratory isolation. What major course of therapy should this patient
receive?
Answer Choices
1 Steroids
2 Supportive care
3 Antibiotics
4 Transfusion
5 Bacterici - ANSWER-Antibiotics
Antibiotics are the treatment of choice for meningococcemia. The preferred drug for
active infection is penicillin G. For those allergic to penicillin, chloramphenicol and
cephalosporins (ie, cefotaxime, cefuroxime) may be used as alternatives.
Patients will also receive supportive care, but antibiotic therapy must be initiated
quickly if the patient is to survive. Intensive care placement may be necessary if organ
failure is imminent. Ventilatory support, inotropic support, and IV fluids are necessary
in some. If adrenal insufficiency occurs, corticosteroid replacement may be considered.
A central venous line helps to provide large amounts of volume expanders and
inotropic medications for adequate tissue perfusion.
Steroids have not been shown to play a major role in the treatment of
meningococcemia. However, they have been used in addition to antibiotic therapy. In
the case of adrenal insufficiency, for example, steroid replacement has been shown to
be beneficial.
Transfusion does not generally play a major role in treatment. If the patient suffers
