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Neuro approach to Pt
Neurology
| Question | Answer |
|---|---|
| Key point question | when did the patient last feel perfectly normal? |
| Light-headed? | Cardiovascular |
| off-balance | Cerebellar |
| History | the key is to get the progression of actual symptoms rather than a litany of diagnostic procedures and specialty evaluations |
| Past Medical History | Trauma, meningitis, encephalitis, polio, deformities, congenital anomalies, cardiovascular problems (htn, aneurysm, stroke), neuro disorders (stroke) |
| Family History | Hereditary disorders, alcoholism, mental retardation, seizure, headache, alzheimer's, learning disorders, weakness or gait disorders, medical/metabolic disorders (DM, thyroid, HTN) |
| Personal History | Environmental or occupational hazards (lead, arsenic, insecticides, chemical, heights, water), hand, eye, foot dominance, ability to care self, sleeping/eating habits, sexual contacts, alcohol and drugs |
| Review of Symptoms | Syncope, Seizures, Weakness of paralysis, Problems with sensation or coordination, tremors |
| Pain is a symptom of? | lesion in the PNS |
| Aphasia is a symptom of? | Lesion in the CNS |
| Coexistence of sensory loss and motor dysfunction in a limb implies | either a large lesion at the level of the cortex or a smaller lesion lower in the neuraxis |
| How do degenerative diseases progress? | Gradually |
| Which diseases occur more rapidly? | Vascular diseases (stroke, aneurysmal subarachnoid hemorrhage) |
| Common signs and symptoms | headache, dizziness, vertigo, weakness, numbness or loss of sensation, loss of consciousness, syncope, seizures, tremors or involuntary movements |
| Mental status observations | changes in attention, mood or speech, changes in insight, judgment, orientation or memory. Anxiety, panic, phobias, delirium, dementia |
| High indicators of location | focal weakness, sensory loss or pain, visual loss, language disturbance |
| Medium indicators of location | vertigo, dysarthria, clumsiness |
| Low indicators of location | fatigue, headache, insomnia, dizziness, anxiety/confusion |
| Cerebral Hemispheres signs: | unilateral weakness or sensory complaints, language dysfunction, spatial disorientation, hemivisual loss, flattening of affect or social dysinhibition, alteration of consciousness and alteration of memory. |
| Cerebellum signs: | expect limb clumsiness, unsteady gait or posture |
| Basal Ganglia signs: | expect slowness of voluntary movement and involuntary movement |
| Brainstem signs: | expect contralateral weakness or sensory complaints in the body, with ipsilateral weakness or sensory complaints in the face, double vision, vertigo, alteration of consciousness |
| Spinal cord Signs: | expect weakness and spasticity and anesthesia below a specified level, unsteadiness of gait, bilateral (can be asymmetric) weakness and sensory complaints in multiple contiguous radicular distributions. |
| General survey key point | symmetry, cause PNS or CNS?, Mental status, speech, cranial nerves, motor system, sensory system and reflexes |
| Head | Trauma, dysmorphism, bruits |
| Neck | tone, bruits, thyromegaly |
| Cardiovascular | rate, rhythm, murmurs, pulses, JVD |
| Pulmonary | Breathing pattern, signs of cyanosis |
| Abdomen | hepatosplenomegaly (liver dz causing toxic metabolites) |
| Back and extremities | Skeletal abnormalities, edema |
| Skin | Neurocutaneous or hepatic stigmata. Medussa veinage |
| PE Mental status exam | LOC, Attention (coherent stream of thought, serial 7s), Orientation (temporal, spatial), Memory (short-term and long-term), Language (naming, repitition, comprehension, fluency, reading, writing) |
| How do you evaluate visuospatial skills | clock drawing, figure copying |
| Maximum amount of points you can score on a mini-mental status exam? | 30pts |
| MMSE > or = 21 | Mild |
| MMSE 10-20 | Moderate |
| MMSE < or = 9 | Severe |
| Smell assesses | CN I |
| Extraocular movements and parasympathetic changes assess | CN III - oculomotor |
| Trochlear, motor: downward and inward eye movement | CN IV |
| Jaw clenching | CN V |
| Teeth, tongue, ear and facial skin | CN V |
| Gag reflex | CN IX |
| Peristalsis | CN X |
| Turn head, shrug shoulders, some phonation | CN XI - spinal accessory |
| Tongue movement for speech, sound articulation and swallowing | XII - hypoglossal |
| Diplopia | CN III, IV, VI |
| Decreased facial sensation | CN V |
| Deafness and Dizziness | CN VIII |
| Dysarthria and Dysphagia | CN IX, X, XII |
| Decreased strength in neck and shoulder | CN XI |
| What numerical scale is used to evaluate power of major muscle groups? | 0-5 |
| Light touch tracts | Posterior Columns |
| Pain Tract | Spinothalamic tract |
| Temperature Tract | Spinothalamic tract |
| Joint position sense | Posterior column |
| Vibration | Posterior column |
| Graphesthesia | Write a number or a letter on their hand. Cortical sensory |
| Two-point discrimination | Posterior columns, cortical sensory |
| Double simultaneous stimulation | Touching both shoulders with fingers, cortical sensory |
| On what numerical scale are reflexes evaluated? | 0-4+ |
| Myerson's | usually seen in Parkinson's. Inability to stop blinking in response to tapping the forehead, nasal bridge or maxilla |
| Snout | scratching upper lip induced a puckering movement |
| Jaw jerk | (if brisk) When mouth is partially open and muscles relaxed tapping the chin causes the jaw to close. (Reflex center midpons) |
| Palmomental | (if present) Vigorous scratching of thenar eminence causes ipsilateral contraction of the muscles of the chin. |
| Hoffman Sign | (if brisk) flexion and sudden release of the terminal phalanx of the middle finger results in reflex flexion of all the digits. |
| DTR's increased in | UMN involvement |
| DTR's decreased in | LMN involvement |
| Differential Dx | Genetic, neoplastic, vascular, infectious, degenerative, autoimmune, toxic/metabolic, other structural such as trauma, hydrodynamic, psychogenic, spinal cord injury |
| Top 15 for Primary Care | HA, Dizzy, Weakness, Seizures, Epilepsy, TIA, Stroke, tumors, pseudotumor cerebri (with young obese women, look in eye for swelling around optic disc), Dementia, MS, Injury, Neuralgias, Aneurysm, Parkinsons, Tremor, Tourette's, Bells Palsy |
Created by:
ltm12