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1

What questions do we need to ask ourselves about a lesion?

Where is it? One or multiple? Confined to NS or systemic dz? What part of NS is affected? Is it a tumor, infection, or hemorrhage?

2

In Past Medical Hx what organ systems do we need to explore?

Cardio (HTN, CVD?), Neuro (Stroke, TIAs, Psychiatric illness?), Endocrine (DM?), Hepatobiliary (Liver dz?), Trauma (TBI, Concussion, MVA?), Overall systemic (CA?)

3

In Family Hx what diseases should we ask about?

Alzheimer's, Parkinson, CVD

4

What should we ask about in ROS?

Any pain. HEENT: Headache, visual changes, dizziness.
Neuro: Tremor, weakness, sensory loss, LOC, motor dysfunction, speech or swallowing concerns.

5

2 Mental Status Exams

FOGS, Mini mental status exam (MMSE), and Montreal Cognitive Assessment (MoCA)
F- Family Story of Memory Loss
O- Orientation (to precise time month, day, year)
G- General Information (president & vp of the US)
S- Spelling (spell "world" forward & back, if not, then try a 4 letter, then a 3 letter word).

6

Testing CN 1

Olfactory nerve. Can be helpful if a frontal lobe lesion suspected (personality change, hemiparesis, unexplained visual loss).
Test each side w/a mild agent (soap, coffee, chocolate)

7

Testing CN 2

Optic nerve. Visual fields near & far, gross fields, opthalmoscopic exam.

8

Testing CN 3, 4, 6

Oculomotor, Trochlear, Abducens. PERRLA & H + X in space.

9

Testing CN 5

Trigeminal. Stimulate nerve distribution with light touch.

10

Testing CN 7

Facial nerve. Smile.

11

Testing CN 8

Vestibulocochlear. Can they hear your fingertips moving?

12

Testing CN 9, 10

Glossopharyngeal, Vagus. Gag reflex.

13

Testing CN 11

Spinal Accessory. Shoulder elevation.

14

Testing CN 12

Hypoglossal. Stick out the tongue.

15

Motor System test - pronator drift

Upper extremity drift (pronator drift). Stand with eyes closed & arms forward horizontally, palms up for 15-30 sec. If (+) a hand will drop and rotate in b/c pronators are stronger. Suggests an upper motor neuron lesion.

16

Coordination test - finger-to-nose, heel-to-shin

Awkwardness of movement in cerebellar lesions.

17

Balance test - Rhomberg

Everyone needs 2 of vision, vestibular sense, and proprioception to balance. (+) test is that the pt sways when they close their eyes. *Not positive if they sway before they close their eyes.

18

Babinski reflex

Abnormal dorsiflexion of big toe & fanning of the other toes when the bottom of the foot is stroked. Normal in infants, goes away. (+) indicates upper motor neuron lesion. (UMN lesion)

19

Meningitis tests

Kernig - pain in low back on straightening lower extremity.
Brudzinski - flexion of head results in neck pain & involuntary flexion of the hip and lower extremities

20

In general, what 4 labs might we want to run?

CBC (infection, anemia), CMP (electrolyte, kidney, blood sugar), TSH, **Bedside glucose (starred b/c we can do it in office, WHILE waiting for an ambulance if need be)

21

In general, what are the 3 biggest imaging/procedures we might need?

CT (faster), MRI (smaller bleeds), Lumbar puncture

22

Stroke - Definition & overview

Sudden interruption of cerebral blood flow that results in neurologic deficit. Third most common cause of death & most common cause of neurologic disability. A stroke involving the internal carotid may affect the anterior 2/3 of the brain and is likely to have *unilateral sxs*. A stroke involving the vertbrobasilar arteries may affect the posterior portion of the brain (temporal, parietal, brainstem, cerebellum), *can have unilateral or bilateral sxs, and is more likely to affect consciousness*

23

Stroke - Risk Factors

*Old age, HTN, Cigarette smoking*, prior stroke, family hx, alcoholism, male sex, hypercholesterolemia, diabetes, some drugs (cocaine, amphetamines), abdominal obesity, lack of physical activity, hypercoagulability.

24

Stroke - SSx & FAST

*Occur suddenly. HA that is sudden, severe, "different," Contralateral limbs affected,* numbness, weakness, or paralysis of face or contralateral limbs, aphasia (difficulty speaking or understanding), confusion, visual disturbances in one or both eyes, dizziness or loss of balance & coordination.
F- facial asymmetry/drooping. A- arms & arm weakness, S- Speech, T- time (onset & call 911 NOW!)

25

Etiology of Ischemic Stroke

80% of strokes.
-Thrombosis (Atherosclerosis, vascular inflammation, hypercoagulability disorders, older OCPs),
-Emboli (from cardiac thrombi thrown off in fibrilation, RHD, MI, vegetations, prosthetic valves, or rarely fat emboli, air, or venous clots),
-Lacunar (small vessel dz, usu in older pts with DM or poorly controlled HTN),
-*TIA (transient ischemic attack or "mini stroke"

26

SSx of Ischemic Strokes by type

-Thrombotic: often occur at night, noticed on waking. *slower onset of sx* 24-48hrs "evolving stroke," may look like dysfunction beginning in 1 arm & then spreading ipsilaterally. *Extends without HA, pain, or fever*
-Embolic: *Quicker onset* occuring in minutes, often during the day, *HA may precede neurologic deficit*
-Lacunar: she isn't testing on (and TIAs aren't mentioned here)

27

Dx an Ischemic Stroke

Usually Dx is clinical. CT (faster) & MRI (smaller infarcts). *Do bedside glucose testing to r/o hypoglycemia!*

28

DDx for Ischemic Stroke

**Hypoglycemia,** postictal paralysis, hemorrhagic stroke, migraine, tumor, systemic conditions (Guillan Barre, Bell's Palsy), Syncope

29

Etiology of Hemorrhagic stroke

20% of strokes - focal bleeding from a blood vessel in the brain parenchya, usually caused by *HTN*
Less commonly- arteriovenous malformations (AVMs), Aneurysm, Trauma, Brain tumor, Bleeding disorder.

OR Subarachnoid Hemorrhage, usually caused by ruptured aneurysm.

30

SSx of Hemorrhagic stroke by type

Bleed into Parenchyma: Focal neuro deficit (already concerning) w/*HA, Nausea, Impaired consciousness,* nausea, vomiting, delirium, focal or generalized seizures, s/t hemiparesis or brain stem/cerebellar dysfunction.
SAH: *Severe sudden HA with LOC, severe neurologic deficits*, seizure possible, no neck stiffness, m/b vomiting.