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77 Cards in this Set
- Front
- Back
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what is the most important part of the neurological exam
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gait testing - heel, toe, tandem, not when they first walk in
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what are important inspection techniques of a neuro exam
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inspect posture
general activity level and look for tremor and involuntary movements weakness - stroke observe size and contour of muscles for atrophy, hypertrophy, asymmetry |
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what disease makes you walk and drag feet
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parkinsons
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when you stomp or slap feet on ground when walking what is that
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neuropathy - try to feel floor
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when circumducting hip with walking, worse with upper extremity - retraction of the arm - what type of stroke
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middle cerebral artery territory
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what are the UMNL -
what neuron order, part of what part of nervous system how is body tone reflexes what is the babinski will they have muscle atrophy is there fasciculations fine or gross motor |
first order neuron
Central NS Fine rapid movements most affected increased tone increased reflexes Babinski - fanning extensor no muscle atrophy no fasciculations - rigid |
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what are the LMNL:
what neuron order, part of what part of nervous system how is body tone reflexes what is the babinski will they have muscle atrophy is there fasciculations fine or gross motor |
second order neurons
nerve roots or nerves - peripheral all movements equally affected decreased tone decreased reflexes no babinski - flexor muscle atrophy fasciculations |
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what are pyramidal cells and part of what system
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first order neuron - giant in cortex, where it originates, part of the motor system
medulla/brain stem - decusates, cross over, to then descend as the lateral coritcospinal tract down the spine until it hits the second motor neuron |
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what is a first order neuron
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where it originates, starts to descend in spinal cord.
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what is second order neuron; what is an example
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where neurons contact in anterior horn of the spinal tract - before it leaves
also lower motor neuron ex fascial nerve - first order in pyramidal, then brainstem makes it a second order |
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when you have a stroke, you will see facial paralysis which is what type of motor neuron? What would transection of everything else distal to that location be?
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facial - LMNL
under the facial nerve- UMNL - because it is not to its destination yet. |
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what does the extrapyramidal system do
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smooths out the pyramidal system, coordination, originate in basal ganglia, with involuntary movement and modulation of movement
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what does the extrapyrimidal system control
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gross motor
muscle, speech and swallowing facial expression |
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what are common neuro complaints in primary care
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pain syndromes
dizziness stroke seizures dementia tremor disorders MS sleep disorders |
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what is hemiplagic migraine
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autosomal dominant, migraine with aura with motor weakness, and reversible sensory or visual changes - 30-60minutes before
neuro defects by 30's - permanent - hemipalgea of the entire body - associated with ataxia, coma and seizures must do genetic studies over diagnosed, must do genetic studies |
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what are symptoms of parkinsons
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tremor at rest
bradykinesia flexed posture loss of postural reflexes freezing phenomena |
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why do you need to know the functional status of migraines
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because they could have a migraine twice per year but out of work for 5 days each verses someone who has migraines a few times a year but can take Motrin and do not miss work do not need a preventative.
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when would you get imagining with headaches
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first and worst headache
focal neurological deficits >50 years old with new types of HA |
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why should you treat chronic pain?
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to avoid rewiring of limbic system, desensitization, whole pathway starts to form. Makes it very difficult to treat.
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patient has history of migraines, what focal deficits are you concerned about, came in to see you after a while?
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any deficit, should not have any!
if they have any, must refer and do imaging. |
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what percent of motor or sensory symptoms (deficit) are all LBP
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1%
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what are the most common pain syndromes for LBP
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discogenic - cytokines in between discs and myofascial symptoms
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what is the treatment for discogenic LBP
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tylenol
NSAID topical opiods PT facet joint injections nerve block with radicular pain |
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what does chronic narcotics use cause
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opiod analgesic syndrome - cause pain - severe that is not responsive to anything
must taper off and try something different, why you need to refer out - support of psych and social works as well as nonpharm therapy |
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this is pain that persists after healing has occurred, result from long term illness, has no cause
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chronic pain - does not respond to treatment
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what are causes of chronic pain
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cancer
degenerative disease - OA or OP fibromyalgia Inflammatory disease - rheumatoid arthritis Neurogenic pain - both central - MS and stroke, and peripheral - neuropathy Parkinsons - limb pain |
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what is the goal for treatment of chronic pain
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to control pain not complete pain relief
decrease in 30% in either intensity or frequency of pain is considered a success |
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what are some chronic pain treatment options
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physical therapy
massage therapy - aqua stimulates endorphin production Meds - short acting - NSAIDS, tylenol or narcotics Meds - long acting - TCAs, Lyrica, Cymbalta, AEDs - Topamax, Neurotin, Tegretol TENS Patches - lidocaine, fentanyl Trigger point injections Radioablation Pain pacemaker Nerve blocks Botox good for those who cannot do aqua therapy bc of psoriasis, open sores or MS, stroke. |
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what do you need to check with TCAs
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ECG - QT interval
use low dose, ok with heart condition |
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what history should you obtain with dizziness
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describe symptoms: feel drunk, light headed, spinning
when does it occur - turn, sit, standing, coughing, laying in bed Has it ever happened before, syncope vs seizure associated symptoms - tinnitus, hearing loss, |
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who are more common to have drop attacks
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young people. child with MR or CP
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what is vasovagal syncope
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slump over for a few seconds, no post-dictal, did not LOC, some shaking, lost urination (autonomic), no history of migraines,
had one episode before - occur when watching TV, this time watching computer |
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what would you do in your exam for vertigo
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orthostatics - laying and standing, 5 minutes apart, with increased age may take longer to accommodate
Nystagmus - Dix hallpike Check neuropathy - decreased balance without eyes open - will be positive Rhomberg with neuropathy, so cerebella non specific Coordination - cerebellar function check cranial nerves reflexes hearing |
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what is central vs peripheral vertigo
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peripheral - improves with eyes open
central - does not matter if eyes are open or closed |
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what signs of vertigo suggest imaging
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progressive worsening of vertigo over weeks to months
progressive tinnitus and deafness unilaterally - acoustic neuroma accompanying sensory or motor deficit of the face or body - cranial nerves, multiple neuropathies of cranial nerves is most likely the cause of a brain stem issue |
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how do you evaluate vestibular function
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cold caloric - should produce nystagmus
Nystagmography - record eye movement vestibulo-ocular reflex - head thrust move head and eyes will correct back to center if asymmetric neuroma, can occur B4 vertigo symptoms |
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what is intorsion or extorsional nystagmus
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rotatory intorsion is toward the nose, extorsion away from nose
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how do you know which ear is affected with Dix Hallpike
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right ear down and has rotatory nystagmus, right ear is the issue - whichever is down
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what are treatments for peripheral vertigo
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Epley maneuver - 80% effective, like dix hallpike
Brandt-Daroff Exercise |
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what is the treatment with Neuropathy
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if dizzy neurotin will not help
assistant devices, learn to use visual cues treat underlying condition |
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what is the treatment for orthostatic vertigo
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dehydration
switch medications make sure to drink 4-6 glasses of water tilt table - autonomic testing atenolol to help vertigo -take before bed change times of medications so that the peak is when the person is sleeping, so it will not drop steriods aqua therapy compression stockings |
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what are the common causes of syncope
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cardiogenic event
unknown - vasovagal, autonomic, etiologic very small percent of neurological |
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what must you do in your evaluation of syncope
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Orthostatic are necessary - drop in 20/10 in 3 minutes and increase in 30bpm or >120bpm
tilt table - check vagal check hydration and nutrition cardio referral rule out psych - hyperventilate, DM - autonomic issue, need to rule out seizures - get ECG to check arrhythmia, event monitor assess RF: heart disease, arrhythmia, electrolyte disturbance, BNP |
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what is the treatment of syncope
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first treat where it is coming from - if orthostatics
water therapy compression stockings Florinef - help orthostatic hypotension Midodrine - used for orthostatic hypotension, increase BP while supine |
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what are symptoms of vasovagal
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nausea warmth pallor lightheaded
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what are partial seizures
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focal - one focus
no LOC etiology - only one focus area |
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what are generalized seizures
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LOC
entire brain etiology - seen on EEG 90% more complex - entire brain involved |
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what is the difference between simple vs complex partial seizures
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simple without LOC and complex has LOC
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what are the symptoms of simple partial seizures
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no LOC
sensory - repetitive feeling motor - movement autonomic - n/v, sensation coming over them psychic - see something EEG normal in-between sz Stereotypical , same every time higher coricol symptoms - deja vu, distortion of time |
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what are symptoms of complex partial seizures
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LOC
automatisms - repeating motions lip smakcing, glazed look, move hands around - will clean a room, does not remember, happens every time. stereotypy - same part of the brain affected aura most common with new onset sz in adults |
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what are peitit mal seizures
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space out, absence - generalized
only has a child, can subside or develop into tonic clonic once an adult |
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what are grand mal seizures
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tonic clonic, start with ridgity and movement
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what are myoclonic seizures
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jerking of extremities
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what are tonic seizures
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generalized sz
stretching |
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what are clonic seizures
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generalized sz
jerking |
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what are atonic seizures
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drop attack
stiffen than pass out seen in children ONLY MR, CP brain issue |
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when are the peaks of seizures - ages?
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childhood and then again after 50 years
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when do you check levels with seizure patients
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when admitted with sz
sx of toxicity when starting medication or adjusting dose when still sz and on high dose when non-sz for 6-8 months, then check level to see what works if provoked sz do not treat, if the unprovoked sz >1 must treat signs of toxicity - nystagmus, incoordination, cerebellar issue levels are so broad, so a random level does not mean anything |
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what are some older seizure medications
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dilantin
depakote tegretol - carbamazepine phenobarbital |
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what are some newer seizure medications
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Lamictal
Keppra Topamax Felbatol Cerebryx Trileptal Neurotin - increased SE, do not use for seizures, poor compliance |
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what are the newest seizure medications
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Zonegran
Sabril Lyrica Vimpat Banzel |
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what if the level is low on medications for seizures but having no seizures do you switch
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no - leave because they are not seizing
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if the seizure medication level is elevated but having no sz and no SE what should you do
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not change it, focus on SE and no seizures - whichever comes first
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which 2 medications for seizures are no metabolized by the liver
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neurotin and keppra
helps with interactions Lacosamide and Vigabatrin - partially metabolized by liver, give IV load, may have rash at first, if taken low dose then an IV dose, steven john sons |
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when do you d/c medications for seizures
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one generalized seizures, negative EEG and patient willing to forgo driving for 3-6 months
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when do you treat in regards to treatment
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generalized tonic clonic - must have 2 seizures
one complex partial seizure because has a focus |
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what is the treatment for painful neuropathy
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TCAs
tegretol neurotin capsaicin cream |
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what labs will you order with a patient with neuropathy
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ESR
RPR B12 Folate can check MMA level - works to attach to B12 to work, if high then B12 low and have to replenish |
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what are common causes of neuropathy
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DM
ETOH Hereditary Idiopathic |
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what is meralgia paresthetica
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numbness of anterior thigh
associated with RLS or periodic limb movement of sleep |
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what is the treatment for RLS or PLMS
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Mirapex, Requip, or Senemt
neurotin and opiates |
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how does essential tremor differ from parkinsons
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action tremor
postural tremor everything else is WNL - except tremor normal tone normal movement bilateral familial assymetric - arms>legs tremor worse with action present, the longer they work at it the worse it is |
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when would you see micrography
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parkinsons
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what are SE of parkinsons medicaitons
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disinhibition syndrom - spend all retirement money, flashers, sleepy
if stop abruptly - neurologic malignant syndrome, autonomic disorder - fever seizures, mortality 80% CAUSE SEDATION!!! |
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what are the treatments of parkinsons medications
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requip and mirapex - dopamine agonists
watch disinhibition syndrome |
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what is the main treatment for essential tremor
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primidone and propanolol, remeron, topamax, diamox,
deep brain stimulation assistive device - weighted utensils, writing tablet, weighted travel mugs, OT the wider, heavier the more stable it is - wrist weights |
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what causes neuroleptic malignant syndrome
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sinemet - carbidopa and levodopa
very rare, but can kill, a huge issue, must taper and not stop suddenly |
