Neurology

You respond to a 71-year-old female who her son says has been increasingly confused over the past 3 weeks since she started a new blood pressure medication (hydrochlorothiazide). She is confused today. BGL is 88, HR 76, BP 112/68, GCS 12. She is on a low-sodium diet and has been drinking large amounts of water. She has no fever. What electrolyte abnormality should you suspect?

• A.Hyperglycemia — check a repeat blood glucose
• B.This is dementia progression — no acute treatment needed
• C.Hyperkalemia — the diet change caused elevated potassium
• D.Hyponatremia from HCTZ-induced sodium wasting combined with excess free-water intake and a low-sodium diet

At a hotel room, a 40-year-old male has one-sided weakness that resolved before you arrived. What is appropriate?

• A.No transport advice
• B.Give glucose only
• C.Treat as possible TIA
• D.Cancel evaluation

At a restaurant, a 31-year-old male head injury patient vomits and becomes harder to arouse. What does this suggest?

• A.Routine fatigue
• B.Neurologic deterioration
• C.Safe refusal
• D.Simple nausea

You respond to a 45-year-old male who woke up this morning unable to move his right arm and leg. He went to sleep at 11 PM and was found at 7 AM with right-sided weakness. His wife says he was completely normal when he went to bed. He has a history of AF and takes warfarin. He has difficulty speaking but can understand commands. What is the significance of the last known well time being 11 PM the previous night for thrombolytic eligibility?

• A.His warfarin makes last known well time irrelevant
• B.The time does not matter — all strokes get tPA
• C.Document last-known-well time
• D.All AF patients with stroke receive the same

You are treating a 22-year-old male who was assaulted and has a head laceration. He was briefly unconscious at the scene but is now GCS 15 and talking normally. En route he falls asleep and you cannot wake him. His left pupil has become larger than his right and sluggishly reactive. HR has dropped from 88 to 56. His BP has risen from 132/84 to 180/60. What is occurring?

• A.Hypoglycemia — administer oral glucose
• B.He is seizing — administer oxygen
• C.He fell asleep because he is tired — this is normal post-trauma
• D.Epidural hematoma with the classic lucid interval followed

You respond to a 67-year-old male who is confused. His wife says he has been increasingly forgetful for 3 months. Today he had a generalized tonic-clonic seizure lasting 2 minutes followed by post-ictal confusion. He has lost 5 kg over 2 months and has daily headaches. GCS is 11. BP is 148/88. BGL is 92. What does new-onset seizure with progressive cognitive decline and constitutional symptoms in an older adult suggest?

• A.Alzheimer's disease — seizures are common in late dementia
• B.Medication-induced seizure from new prescriptions
• C.Late-onset idiopathic epilepsy — common over age 60
• D.A structural brain lesion

You respond to a 25-year-old male who was involved in a fight and received multiple blows to the head. He is conscious and oriented with GCS 15. He has a 4 cm laceration to his scalp that is bleeding moderately. His pupils are equal and reactive. He has no focal neurological deficits. He refuses transport because he feels fine. He is with friends who say they will watch him. What specific instructions are critical for the sign-off of this patient?

• A.Provide return precautions verbally and in writing
• B.He is GCS 15 so no specific instructions are needed
• C.Tell him not to sleep for 24 hours
• D.Tell him the injury was minor and he will be fine

You respond to a 44-year-old male with a severe headache. He reports the headache started gradually 4 hours ago on his left side and has built slowly to 8/10 intensity. He has had similar headaches before. He is nauseated and sensitive to light. He is lying in a dark room. GCS is 15. BP is 138/84. No focal neurological deficits. How does the onset pattern of this headache help distinguish it from subarachnoid hemorrhage?

• A.Migraines always cause fever — the absence of fever means SAH
• B.This headache built gradually over 4 hours
• C.A gradual onset headache can still be SAH
• D.Both conditions have identical onset patterns

You respond to a 33-year-old female with a 2-hour history of right-sided facial droop, right arm weakness, and difficulty finding words. Her symptoms have been fluctuating — they are present now but were briefly better 45 minutes ago. BP is 164/98, HR 88, GCS 14. She is 8 months pregnant. Does pregnancy change the stroke treatment approach?

• A.Pregnancy contraindicates all stroke treatment including transport
• B.Stroke symptoms in pregnancy are always from eclampsia
• C.Rapid stroke-center transport
• D.Rapid stroke-center transport

You respond to a 48-year-old male who reports that over the past 3 days he has developed bilateral lower extremity weakness and is now unable to walk without holding onto the wall. He reports tingling in both feet. He had a respiratory infection 2 weeks ago. His deep tendon reflexes are absent bilaterally in the lower extremities. He is having difficulty taking a deep breath. RR is 24 with shallow tidal volume. What is the single most important assessment finding to monitor every 5 minutes?

• A.Tidal volume and respiratory effort
• B.Blood pressure — autonomic dysreflexia is the primary concern
• C."Heart rate — GBS causes severe cardiac arrhythmias"
• D.SpO2 — when this drops below 94% begin BVM

You respond to a 52-year-old male with a 3-day history of progressive leg weakness and tingling. He reports his grip is now also weak. He had a respiratory infection 3 weeks ago. You are assessing him for transport when he suddenly reports he cannot catch his breath. RR is 30 with very shallow breaths. SpO2 drops from 95% to 87% during your assessment. What specific monitoring finding should prompt immediate BVM-assisted ventilation?

• A.GCS below 8
• B.SpO2 below 80%
• C.Tidal volume assessment
• D.Heart rate above 120

At a dialysis center, a 68-year-old male is unconscious after unknown downtime. Which neurologic-related EMT-B assessment is useful?

• A.Lumbar puncture
• B.Blood glucose
• C.IV sedative
• D.CT scan

You respond to a 61-year-old female with sudden onset of confusion and left-sided weakness. Her son says she was normal 40 minutes ago. You apply the Cincinnati Prehospital Stroke Scale. She has left facial droop, left arm drift, and her speech is slurred. Her BP is 196/118. GCS is 13. What BP management is appropriate for this suspected stroke patient?

• A.Administer nitroglycerin to bring BP below 160
• B.Do not attempt to lower the BP
• C.Give aspirin to reduce the vascular inflammation causing
• D.Lower the BP aggressively

At a mall corridor, a 45-year-old female has seizure history but is now febrile and confused. What should you avoid?

• A.Assessing airway
• B.Assuming routine seizure only
• C.Checking glucose
• D.Transporting

You respond to a 63-year-old male who woke up 2 hours ago with the worst headache of his life. He says it started instantly at maximum intensity while he was asleep. He has had migraines in the past but says this is completely different. GCS is 14. BP is 186/108. SpO2 96%. No focal neurological deficits. He vomited once. How does the onset pattern of this headache differentiate it from his prior migraines?

• A.Migraines are always more severe than subarachnoid hemorrhage
• B."Both conditions present identically
• C.A subarachnoid hemorrhage headache classically reaches maximum
• D.Migraines can present as thunderclap headaches equally often

You respond to a 44-year-old male who woke up with right-sided arm numbness and tingling. He reports it feels like his arm is asleep and it started when he woke up. He has had a headache since yesterday. He fell asleep on his recliner in an unusual position. GCS is 15. BP is 128/78. No facial droop. No arm weakness. No speech difficulty. CPSS is negative. He thinks it is just from sleeping funny. Should you accept this explanation?

• A.A negative CPSS confirms it is positional — no transport needed
• B.Transport for evaluation and assess carefully
• C.a negative CPSS rules out stroke in this case
• D.Numbness without weakness is never neurologically significant

A 70-year-old has sudden slurred speech and right arm drift. What information is most time sensitive?

• A.Insurance number
• B.Favorite pharmacy
• C.Last known well
• D.Usual breakfast

At a fitness center, a 24-year-old female is confused after a fall and repeatedly asks the same question. What should you suspect?

• A.Normal memory
• B.Simple hunger
• C.No concern
• D.Head injury

At a soccer field, a 30-year-old female has altered mental status and glucose of 39 mg/dL but can swallow. What is best?

• A.Nitroglycerin
• B.Aspirin
• C.Oral glucose
• D.Charcoal

You respond to a 52-year-old male with sudden onset of the worst headache of his life while he was straining at the gym. He is conscious but vomiting and very photophobic. GCS is 13. BP is 196/118. He has mild neck stiffness. No focal neurological deficits. CT of the head will be performed at the hospital. What does a normal CT of the head NOT exclude and what additional test is required?

• A.CT is 100% sensitive for SAH — no further testing is needed
• B.A normal CT confirms the headache is benign
• C.A normal head CT does not exclude subarachnoid hemorrhage
• D.A normal CT excludes all causes of thunderclap headache

You respond to a 44-year-old male who reports a sudden severe headache that he describes as the worst headache of his life. It started during vigorous exercise 30 minutes ago with thunderclap onset. He vomited once. He is conscious with GCS 14, HR 72, BP 168/104, temperature 37.0, SpO2 97%, meningismus is absent. What is the priority diagnosis to rule out?

• A.Hypertensive crisis — administer NTG for the BP
• B.Heat stroke from exercise — apply cooling measures
• C.Tension headache from exercise — administer oral fluids
• D.Subarachnoid hemorrhage

You respond to a 52-year-old male whose wife says he suddenly could not speak clearly and dropped his coffee cup about 40 minutes ago. Symptoms lasted about 8 minutes then fully resolved. He is now GCS 15, speaks normally, and has full strength bilaterally. BP is 172/106. He thinks he does not need to go to the hospital since he is completely back to normal. What is the stroke risk after a TIA in the first 48 hours?

• A.TIA risk only applies if symptoms lasted more than 30 minutes
• B.TIA stroke risk only applies in elderly patients over 70
• C.Since symptoms resolved he does not need evaluation
• D.Up to 10-15% of TIA patients will have

You respond to a 19-year-old male having an active generalized tonic-clonic seizure. Bystanders say it started 8 minutes ago and he has no seizure history. His SpO2 is 88% during the seizure. He is incontinent. His glucose is 74. What is the PRIORITY management for an actively seizing patient?

• A.Administer oral glucose — glucose 74 may be causing the seizure
• B.Position on side to protect airway from secretions
• C.Force a bite block between his teeth
• D.Restrain the patient and insert an OPA

At a apartment hallway, a 43-year-old male has one-sided weakness that resolved before you arrived. What is appropriate?

• A.Cancel evaluation
• B.No transport advice
• C.Give glucose only
• D.Treat as possible TIA

You respond to a 34-year-old female with sudden onset of severe left-sided orbital headache, left eye tearing, and a runny left nostril. The attacks last 30-90 minutes and occur at the same time each day. She has a prior diagnosis of cluster headaches. This attack started 45 minutes ago. She is in severe distress with GCS 15. BP is 128/78. What is the characteristic pattern of cluster headaches that distinguishes them from migraines?

• A.Cluster headaches are strictly unilateral orbital or periorbital
• B.Cluster headaches always occur bilaterally
• C.Cluster headaches cause aura — migraines do not
• D.Cluster headaches occur in women predominantly