Neuro Cases Part 2

Question 1

What is a tremor?

Answer 1

an involuntary, rhythmic, oscillatory movement of a body part & is most common movement disorder seen in primary care offices

Question 2

resting tremor

Answer 2

happens when body is @ rest

arm resting on table & little fingers are moving

enhanced by mental stress or movement of ANOTHER body part

Question 3

when will a resting tremor diminish?

Answer 3

voluntary movement of that body part

Question 4

action tremor

Answer 4

postural
isometric
kinetic

Question 5

postural tremor

Answer 5

maintaining position v gravity

Question 6

isometric tremor

Answer 6

muscle contraction v rigid stationary object

Question 7

kinetic trmeor

Answer 7

voluntary movement, includes intention tremor which produced w/ target-directed movement

Question 8

enhanced physiologic tremor

Answer 8

low amplitude, high frequency @ rest & during activity

enhanced by anxiety, stress & caffeine

Question 9

essential tremor

Answer 9

most common PATHOLOGICAL tremor

most common in hands & wrists, present w/ different tasks & interferes w/ activities

alcohol can help symptoms

Question 10

parkinsonism tremor

Answer 10

clinical syndrome

start w/ little tremor & may get Parkinson’s dementia

Question 11

what can cause Parkinsons?

Answer 11

various medications (block or deplete dopamine)

Question 12

What is the main presenting feature of Parkinsons?

Answer 12

70% of pts w/ PD have RESTING TREMOR as presenting feature

classic tremor starts as pill-rolling motion of fingers

bradykinesia (difficulty rising from seated position)

Question 13

cerebellar tremor

Answer 13

low frequency, slow intention or postural tremor

usually caused by MS, brainstem tumor

Question 14

psychogenic tremor

Answer 14

difficult to differentiate from organic tremor (real tremor)

abrupt onset, spontaneous remission, changing tremor characteristics, may disappear if distracted

Question 15

History to obtain for tremor

Answer 15

family history of neuro disease

if in older pt w/ gradual onset, likely to be PD or essential

Question 16

what does sudden onset of tremor mean?

Answer 16

psychogenic, related to meds or toxin exposure, brain tumor

Question 17

What should you always ask if pt has a tremor?

Answer 17

if they are concerned about Parkinson’s disease

b/c some features of PT that will guide you

Question 18

signs consistent w/ PD

Answer 18

loss of smell

decreased facial expression

shuffling gait

slowness of thinking

autonomic dysfunction

Question 19

what is very pronounced in parkinsons tremor?

Answer 19

micrographia w/ writing

writing will be so small that difficult to read

Question 20

Case #1 subjective

Answer 20

no medications that would deplete dopamine

Question 21

Working DDX for case #1

Answer 21

Parkinson’s should be higher up on list

Question 22

What would plan be for case #1?

Answer 22

meds
OMM
tests
holistic
referrals 
return (until treatment is solidified)

**want to improve balance

Question 23

dementia

Answer 23

loss of cognitive fxn (thinking, remembering, reasoning) & behavioral abilities to extent that interferes w/ person’s daily life & activities

**5th leading cause of death

Question 24

what happens w/ dementia?

Answer 24

become impulsive b/c are regressing

will stop talking, issues w/ walking & stop eating

need to consider safety measures

Question 25

what usually causes death in pt w/ dementia?

Answer 25

usually an infection or complication from injury

Question 26

prevalence of dementia

Answer 26

the older people get, the more females will have dementia

increases w/ age (females live longer than men)

Question 27

etiologies of dementia

Answer 27

Alzheimer’s disease (NOT reversible)

Delirium (reversible form of altered mental status)

Frontotemporal dementia

Lewy body dementia

Question 28

Cognitive domains

Answer 28

complex attn
executive fxn
language
learning & memory
perceptual-motor
social cognition

Question 29

executive fxn

Answer 29

able to cook & feed themselves but unable to pay bills

issues in completing tasks w/ many steps

Question 30

complex attn

Answer 30

normal, routine tasks take longer

difficulty in completing tasks when many stimuli are present

Question 31

perceptual motor

Answer 31

forget what a screwdriver is for so try to eat it

lose idea about purpose of items

Question 32

language

Answer 32

difficulty finding the correct words, problems understanding verbal & written communication

Question 33

major neurocognitive disorder

Answer 33

significant cognitive decline in at least 1 domain interfering w/ activities of daily living

Question 34

social cognition

Answer 34

apathy, increase in inappropriate behavior, impaired judgment, loss of empathy

Question 35

History for dementia

Answer 35

education, timeline of symptoms

medication review

recent hospitalizations? infection? delirium?

Question 36

exam for dementia

Answer 36

check thyroid (for goiter)

intracranial tumors (CN test)

depression (could lead to psychomotor slowing)

normal pressure hydrocephalus

Question 37

Screening tests for Dementia

Answer 37

Mini Cog

Ascertain Dementia 8 Item

General Practitioner Assessment of Cognition

Question 38

If screening + is positive…

Answer 38

next screen for degree

MMSE (lower score, more significant dementia)

Question 39

what are the next steps for dementia pt?

Answer 39

rule out depression

lab evaluation & neuroimaging for reversible causes of dementia

Question 40

what does indication of stroke for case #2 mean?

Answer 40

vascular dementia

Question 41

what is the DDX for case #2?

Answer 41

Urinary tract infection (incontinence since stroke)

Atherosclerosis

Alzheimers

Delirium

Question 42

what is the plan for pt w/ dementia?

Answer 42

support the patient & the family (pt & caretaker education)