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Injury to what part of the brain would cause a change in personality, behavior, emotion, and intellectual functions?
Frontal lobe
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What does Broca's area control?
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Injury to what part of the brain would cause a change in hearing, taste, and smell?
Temporal lobe
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What does the precentral gyrus control?
Motor movements
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What does the postcentral gyrus control?
Sensory input
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Injury to what part of the brain would cause a change in sensation?
Parietal lobe
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Injury to what part of the brain would cause a change in speech comprehension?
Wernicke's area
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Injury to what part of the brain would cause a change in visual perception?
Occipital lobe
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Injury to what part of the brain would cause a change in motor coordination, equilibrium and balance?
Cerebellum
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What subjective information is important to obtain when taking a pt's history?
- First notice of symptoms
- Progression of symptoms
- What alleviates symptoms
- Family history
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What are the two types of seizures?
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What is the GCS and what is the score based on?
eye/alertness, verbal and motor responsiveness
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What is the scoring for the eye response in the GCS?
- Spontaneous response: 4
- Opening eyes to name or command: 3
- Not opening to other stimuli but will open to pain: 2
- Not opening eyes to any stimulus: 1
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What is the scoring for the verbal response in the GCS?
- Appropriate orientation, conversant. Correct identification of self, place, yr, and mo: 5
- Conversant but confused: 4
- Inappropriate or disorganized use of words, lack of sustained conversation: 3
- Incomprehensible words, sounds (e.g., moaning): 2
- Lack of sound, even with painful stimuli: 1
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What is the scoring for the motor response in the GCS?
- Obedience of command: 6
- Localization of pain, lack of obedience but presence of attempts to remove offending stimulus: 5
- Flexion withdrawal,* flexion of arm in response to pain without abnormal flexion posture: 4
- Abnormal flexion, flexing of arm at elbow and pronation, making a fist: 3
- Abnormal extension, extension of arm at elbow usually with adduction and internal rotation of arm at shoulder: 2
- Lack of response: 1
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When a pt has a GCS of 8 or less is their head injury severe, moderate or mild?
Severe
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When a pt has a GCS of 9 to 12 is their head injury severe, moderate or mild?
Moderate
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When a pt has a GCS of 13 to 15 is their head injury severe, moderate or mild?
Mild
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What might be a possible cause of a lowering of the GCS score from high to low?
Bleeding or hematomas
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What does the olfactory nerve control?
Smell
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What does the optic nerve control and how do you assess it?
- Sensory input from retina
- Bring pen from periphery and ask when they see it (visual field)
- Snellen chart for visual acuity.
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What is CNIII?
Oculomotor
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What does the oculmotor cranial nerve control?
4 eye movements, visual focusing, pupilary constriction and accommodation and convergence
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How do you assess the oculomotor CN?
- Follow the "H"
- Pen light PERRLA
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What does the Trochlear CN control?
Depresses and inwardly rotates the eye
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How do you assess the trochlear CN?
Same as CNIII: Follow "H" and PERRLA
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What does the abducens CN conrol?
Abduction of the eye
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How do you assess the abducens CN?
Same as CNIII: Follow "H" and PERRLA
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What does the trigeminal nerve control?
- Sensory input from the forehead, skin of the cheek
- Motor muscles used for chewing
- Taste
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What are the 3 branches of the trigeminal CN?
- Opthalmic
- Maxillary
- Mandibular division
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What is trigeminal neuralgia?
Demyelination of the trigeminal nerve: causes intense pain that is unbearable. Surgery must cut the nerve.
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How do you assess motor function of the trigeminal nerve?
- Have pt clench their teeth and palpate the temporal and masseter muscles
- Try to separate jaws by pushing down
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How do you test the sensory function of the trigeminal nerve?
Have pt close eyes, lightly touch forehead, cheeks and chin with cotton or gauze.
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How do you test the taste function of the trigeminal nerve?
Soak a cotton tipped applicator with a sweet then sour taste.
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What does the facial nerve control?
- Motor fibers for facial expression
- Sensory fibers for taste in the front part of the tongue
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How do you assess the facial nerve?
Have patient smile, frown, puff their cheeks, raise eyebrows
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What is CNIX?
Glossopharyngeal
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What does the glossopharyngeal CN control?
- Sensory input from pharynx and posterior tongue (taste)
- Motor fibers to pharyngeal muscles (soft palate)
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What does the vagus nerve control?
- Sensory input from viscera of the thorax and abdomen
- Motor fibers to larynx and pharyngeal muscles
- Parasympathetic response to heart, lungs, digestive system
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How do you assess the glossopharyngeal CN?
- Gag reflex
- Say "ah" and "gah"
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How do you assess the vagus nerve?
Say "ah" or "gah"
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What is CNXI?
Accessory nerve
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What does the accessory CN control?
Movement of the muscles of the upper shoulders, head and neck
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How do you assess the accessory CN?
- Shrug shoulders
- Turn head against resistance
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What is CNXII?
Hypoglossal
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What does the hypoglossal CN control?
Muscles of the tongue
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How do you assess the hypoglossal CN?
Stick out tongue, move it side to side, up and down
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What is CNVIII?
Vestibulocochlear
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What does the vestibularcochlear CN control?
Hearing, balance
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How do you assess the vestibulocochlear CN?
Hearing tests (Weber, Rine), balance
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How do you grade motor strength?
- 5: movement against gravity with full resistance
- 4: movement against gravity with some resistance
- 3: movement against gravity only
- 2: movement with gravity eliminated
- 1: visible/palpable muscle contraction but no movement
- 0: no contraction
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How do you assess sensory position?
Have pt close their eyes, hold a digit on the sides and have them name the position digit and if you are moving it up or down
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How do you assess sensory vibration?
Tuning fork
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How do you assess gait?
Walk 10-20 ft and walk back, walk in straight line heel-to-toe
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What is Romberg's test?
Pt stands feet together, arms stretched out at sides, eyes closed and hold position for 20 seconds. Observe swaying/loss of balance.
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What part of the brain is the Romberg's test assessing?
Cerebellum
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Do you want a positive or negative Romberg's test?
Negative: no impairment
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What are the cortical sensory function tests and what are they assessing?
- Two point discrimination, graphethesia (writing on skin), sterognosis (perceiving form and nature of an object): all w/ eyes closed
- Evaluates cortical integration of sensory perceptions
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When testing for sensory perception, should you start with the affected or non-affected side first?
Affected
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How do you grade deep tendon reflexes?
- 4+ very brisk, hyperactive with clonis
- 3+ brisker than average
- 2+ normal
- 1+ diminished, low normal
- 0 no response
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What grades of deep tendon reflexes may indicate disease?
4, 3
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During diagnostics, what differentiates CSF from other body fluids?
Glucose, will dry on gauze with a halo
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How long can HIV asymptomatic stage 2 last and why?
10+ years, because viral load is building and your body is continuously trying to rebuild CD4 cells.
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What number of CD4 cells is considered healthy?
> 500 CD4 T cells/ul
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What number of CD4 cells is when immune function problems begin?
< 500 CD4 cells/ul
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What number of CD4 cells is when severe immune function problems arise?
< 200 CD4 cells/ul
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How is HIV stage 1 classified?
- Acute infection
- Seroconversion - development of HIV specific antibodies
- Viremia - Large amounts of virus in blood
- Flu/mono "like" symptoms within 2-4 weeks
- Very contagious
- Person often unaware of infection
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How is HIV stage 2 classified?
- Chronic infection
- Asymptomatic - virus is active at low levels up to 10+ years
- Symptomatic - CD4 level decreases & viral load increases (fever, night sweats, diarrhea, severe fatigue & outbreaks of: candida, shingles, herpes, etc.)
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What are the symptoms of symptomatic, chronic HIV infection?
- Fever
- Night sweats
- Diarrhea
- Severe fatigue
- Outbreaks of: candida, shingles, herpes
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How is HIV stage 3 classified?
- AIDSHigh viral load
- CD4 count below 200 cells/ul
- Or has an opportunistic infection/cancer
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What is the survival expectancy for AIDS?
3 years
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What is cytomegalovirus treated with?
Foscarnet (Foscavir)
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What is PJP and what is it treated with?
- Pneumocystis Jiroveci Pneumonia
- Sulfamethoxazole/Trimethoprim (Septra DS)
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What are the parenteral risk factors for HIV?
- Blood transfusions (low risk)
- Drug use (sharing needles)
- Needle sticks (low risk)
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What are the sexual risk factors for HIV?
Unprotected sex
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What are the perinatal risk factors for HIV?
- Pregnancy
- Delivery
- Breastfeeding
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What population is the most affected by HIV?
Gay and bisexual men, particularly young African Americans
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What are the HIV testing methods?
- Rapid antibody testing
- Rapid laboratory based tests
- Antibody/Antigen testing
- HIV-1/HIV-2 differentiation immunoassay
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What is the HIV rapid antibody testing?
- At home test w/ saliva/blood
- Tests for antibodies not antigens
- Cannot detect HIV within 2-month window period between infection and detectable viral antibody load
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What is the HIV rapid laboratory based test?
- Elisa w/ blood
- Tests for antibodies not antigens
- Results in 1-3 hours
- Cannot detect HIV within 2-month window period between infection and detectable viral antibody load
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What is the HIV antibody/antigen test?
- Fourth-generation Western blot
- Most accurate
- Gold standard: tests for antibodies and antigens
- If positive, move on to differentiation immunoassay
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What is the HIV-1/HIV-2 differentiation immunoassay?
- Differentiates between HIV-1 and HIV-2
- Results in 20 minutes
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What is HAART?
Highly active anti retroviral therapy
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What is triple therapy?
3 antiretrovirals "the cocktail"
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What is PrEP?
- Preexposure prophylaxis for adults at high risk of sexually acquired HIV
- Tenofovir & Emtricitabine
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What is PEP?
- Postexposure prophylaxis
- Only used in emergency
- Must start w/i 72 hours of exposure
- Taken qd x 28 d
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What are the 5 mechanisms of HIV medications?
- Entry inhibitors
- NRTIs: nucleoside reverse transcriptase inhibitor: blocks RNA --> DNA
- NNRTIs: nonnucleoside reverse transcriptase inhibitor: blocks RNA --> DNA
- Integrase inhibitors: blocks integration of viral DNA into host DNA
- Protease inhibitors: blocks HIV replication at "budding" stage
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What are the benefits of ART?
- Prevent HIV disease progression
- Prevent transmission of infections
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How do they determine ART prescription strength?
- CD4 count
- Transmission risk
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What is the current ART medication and how often to pts take it?
- Complera (Emtriitabine/Rilpivirine/Tenofovir)
- 1x/day
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What is the administration window for ART medications?
Within minutes, must be given at EXACT same time daily.
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What is the recommended initial form of drug resistance testing for HIV drugs and why is it needed?
- Genotype
- Used to select effective ART
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How often do we assess drug adherence for HIV patients?
Every visit
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What is key to ART effectiveness?
Adherence
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What are the components of improved immune function in HIV patients?
- Good nutrition
- Exercise
- Decreased stress
- ART adherence
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What is the pathophysiology of GBS?
- Auto-immune disorder, progresses quickly
- Caused by a loss of myelin and inflammation and edema from autoimmune process in peripheral nerves
- Nerve damage in motor, sensory and autonomic functions
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What triggers GBS?
- Viruses, typically 1-3 weeks prior to symptom onset (CMV, Epstein-Barr, HIV)
- Campylobacter jejuni gastroenteritis
- Trauma
- Surgery
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What are the clinical manifestations of GBS?
- Ascending, symmetric paralysis
- Pain that is worse at night
- Paresthesias
- Hypotonia
- Paresis to quadriplegia
- Diminished or absent reflexes
- Respiratory dysfunction/failure
- Autonomic dysfunction
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What stays intact in GBS?
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How do you diagnose GBS?
- Lumbar puncture w/ elevated protein and normal WBC count
- EMG
- Spinal MRI
- Nerve conduction studies
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How do you score GBS?
- 0 = healthy state
- 1 = minor symptoms and capable of running
- 2 = able to walk 30 ft or more without resistance but unable to run
- 3 = able to walk 30 ft across an open space with help
- 4 = bedridden or chair bound
- 5 = requiring assisted ventilation for at least part of the day
- 6 = death
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How do you treat GBS?
- Plasmapheresis w/i first 2 weeks to remove plasma containing antibodies launching attack on body
- High dose IV IG-G w/i first 2 weeks
- Supportive care
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What does "amyotrophic lateral sclerosis" stand for?
- "A" = no
- "Myo" = muscle
- "trophic" = nourishment
- "Lateral" = where in the spinal cord
- "Sclerosis" = scarring or hardening due to degeneration
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What is the pathophysiology of ALS?
- Motor neurodegenerative disorder in brainstem and spinal cord
- End stage is respiratory paralysis and death
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What stays intact in ALS?
- Cognition
- Bowel & bladder
- Sensory
- Extraocular movements
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What are the clinical manifestations of ALS?
- Striated muscle atrophy
- Muscle weakness
- Fasciculations (muscle twitches)
- Spasticity (muscles continuously contracted)
- Hyperreflexia of deep tendon reflexes
- Increased creatine kinase
- Dysarthria (slurred speech)
- Dysphagia
- Ineffective cough
- Flucuations in BP
- Metabolic changes
- Emotional lability
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What disorder shows a characteristic mark of increased creatine kinase?
ALS
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What disorder shows a characteristic sign of elevated protein in the CSF with normal WBC counts?
GBS
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What is a possible treatment for ALS?
- Riluzole (glutamate blocker)
- Edaravone
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What is edaravone?
ALS medication, slows muscle atrophy
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What is Riluzole?
ALS medication: glutamate blocker
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What is the most common complication of peritoneal dialysis?
Peritonitis
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