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77 Cards in this Set

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what is the most important part of the neurological exam
gait testing - heel, toe, tandem, not when they first walk in
what are important inspection techniques of a neuro exam
inspect posture
general activity level and look for tremor and involuntary movements
weakness - stroke
observe size and contour of muscles for atrophy, hypertrophy, asymmetry
what disease makes you walk and drag feet
parkinsons
when you stomp or slap feet on ground when walking what is that
neuropathy - try to feel floor
when circumducting hip with walking, worse with upper extremity - retraction of the arm - what type of stroke
middle cerebral artery territory
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
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
what are pyramidal cells and part of what system
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
what is a first order neuron
where it originates, starts to descend in spinal cord.
what is second order neuron; what is an example
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
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?
facial - LMNL
under the facial nerve- UMNL - because it is not to its destination yet.
what does the extrapyramidal system do
smooths out the pyramidal system, coordination, originate in basal ganglia, with involuntary movement and modulation of movement
what does the extrapyrimidal system control
gross motor
muscle, speech and swallowing
facial expression
what are common neuro complaints in primary care
pain syndromes
dizziness
stroke
seizures
dementia
tremor disorders
MS
sleep disorders
what is hemiplagic migraine
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
what are symptoms of parkinsons
tremor at rest
bradykinesia
flexed posture
loss of postural reflexes
freezing phenomena
why do you need to know the functional status of migraines
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.
when would you get imagining with headaches
first and worst headache
focal neurological deficits
>50 years old with new types of HA
why should you treat chronic pain?
to avoid rewiring of limbic system, desensitization, whole pathway starts to form. Makes it very difficult to treat.
patient has history of migraines, what focal deficits are you concerned about, came in to see you after a while?
any deficit, should not have any!
if they have any, must refer and do imaging.
what percent of motor or sensory symptoms (deficit) are all LBP
1%
what are the most common pain syndromes for LBP
discogenic - cytokines in between discs and myofascial symptoms
what is the treatment for discogenic LBP
tylenol
NSAID
topical
opiods
PT
facet joint injections
nerve block with radicular pain
what does chronic narcotics use cause
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
this is pain that persists after healing has occurred, result from long term illness, has no cause
chronic pain - does not respond to treatment
what are causes of chronic pain
cancer
degenerative disease - OA or OP
fibromyalgia
Inflammatory disease - rheumatoid arthritis
Neurogenic pain - both central - MS and stroke, and peripheral - neuropathy
Parkinsons - limb pain
what is the goal for treatment of chronic pain
to control pain not complete pain relief

decrease in 30% in either intensity or frequency of pain is considered a success
what are some chronic pain treatment options
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.
what do you need to check with TCAs
ECG - QT interval
use low dose, ok with heart condition
what history should you obtain with dizziness
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,
who are more common to have drop attacks
young people. child with MR or CP
what is vasovagal syncope
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
what would you do in your exam for vertigo
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
what is central vs peripheral vertigo
peripheral - improves with eyes open

central - does not matter if eyes are open or closed
what signs of vertigo suggest imaging
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
how do you evaluate vestibular function
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
what is intorsion or extorsional nystagmus
rotatory intorsion is toward the nose, extorsion away from nose
how do you know which ear is affected with Dix Hallpike
right ear down and has rotatory nystagmus, right ear is the issue - whichever is down
what are treatments for peripheral vertigo
Epley maneuver - 80% effective, like dix hallpike

Brandt-Daroff Exercise
what is the treatment with Neuropathy
if dizzy neurotin will not help
assistant devices, learn to use visual cues
treat underlying condition
what is the treatment for orthostatic vertigo
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
what are the common causes of syncope
cardiogenic event
unknown - vasovagal, autonomic, etiologic

very small percent of neurological
what must you do in your evaluation of syncope
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
what is the treatment of syncope
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
what are symptoms of vasovagal
nausea warmth pallor lightheaded
what are partial seizures
focal - one focus
no LOC
etiology - only one focus area
what are generalized seizures
LOC
entire brain etiology - seen on EEG
90%
more complex - entire brain involved
what is the difference between simple vs complex partial seizures
simple without LOC and complex has LOC
what are the symptoms of simple partial seizures
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
what are symptoms of complex partial seizures
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
what are peitit mal seizures
space out, absence - generalized

only has a child, can subside or develop into tonic clonic once an adult
what are grand mal seizures
tonic clonic, start with ridgity and movement
what are myoclonic seizures
jerking of extremities
what are tonic seizures
generalized sz
stretching
what are clonic seizures
generalized sz
jerking
what are atonic seizures
drop attack
stiffen than pass out
seen in children ONLY
MR, CP
brain issue
when are the peaks of seizures - ages?
childhood and then again after 50 years
when do you check levels with seizure patients
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
what are some older seizure medications
dilantin
depakote
tegretol - carbamazepine
phenobarbital
what are some newer seizure medications
Lamictal
Keppra
Topamax
Felbatol
Cerebryx
Trileptal
Neurotin - increased SE, do not use for seizures, poor compliance
what are the newest seizure medications
Zonegran
Sabril
Lyrica
Vimpat
Banzel
what if the level is low on medications for seizures but having no seizures do you switch
no - leave because they are not seizing
if the seizure medication level is elevated but having no sz and no SE what should you do
not change it, focus on SE and no seizures - whichever comes first
which 2 medications for seizures are no metabolized by the liver
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
when do you d/c medications for seizures
one generalized seizures, negative EEG and patient willing to forgo driving for 3-6 months
when do you treat in regards to treatment
generalized tonic clonic - must have 2 seizures

one complex partial seizure because has a focus
what is the treatment for painful neuropathy
TCAs
tegretol
neurotin
capsaicin cream
what labs will you order with a patient with neuropathy
ESR
RPR
B12
Folate

can check MMA level - works to attach to B12 to work, if high then B12 low and have to replenish
what are common causes of neuropathy
DM
ETOH
Hereditary
Idiopathic
what is meralgia paresthetica
numbness of anterior thigh

associated with RLS or periodic limb movement of sleep
what is the treatment for RLS or PLMS
Mirapex, Requip, or Senemt

neurotin and opiates
how does essential tremor differ from parkinsons
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
when would you see micrography
parkinsons
what are SE of parkinsons medicaitons
disinhibition syndrom - spend all retirement money, flashers, sleepy

if stop abruptly - neurologic malignant syndrome, autonomic disorder - fever seizures, mortality 80%

CAUSE SEDATION!!!
what are the treatments of parkinsons medications
requip and mirapex - dopamine agonists

watch disinhibition syndrome
what is the main treatment for essential tremor
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
what causes neuroleptic malignant syndrome
sinemet - carbidopa and levodopa

very rare, but can kill, a huge issue, must taper and not stop suddenly