Western+Diagnosis+-+Nervous+System

Dementia Headache Vertigo Seizures Insomnia Cerebrovascular Disease Multiple Sclerosis Parkinson's Disease Peripheral Neuropathies Meningitis CNS Neoplasms

Neuro-Psychiatric Panic Attacks Anxiety Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder Depression Bipolar Disorder Schizophrenia Personality Disorders

Bell's Palsy Chorea Coma Down's Syndrome Fainting Heatstroke Hypothermia Intercostal Neuralgia Motion Sickness Muscular Dystrophy Myasthenia Gravis Narcolepsy Paralysis Parasthesia Poor Memory Addiction Withdrawal

Alcoholism Anger Anorexia Nervosa Anxiety Attention-Deficit Disorder Autism Bipolar Disease Bulimia Depression Fear Grief Insomnia Nightmares Post-Traumatic Stress Disorders (PTSD)

=Anatomy and Physiology= A. brain 1. cerebrum a. cerebral hemispheres b. cortex i. gray matter - neurons ii. white matter - myelinated axons c. motor, sensory, associative i. emotion, intellect d. basal ganglia i. large automatic muscular actions ii. control center e. limbic system i. “emotional” brain ii. pleasure, pain, etc. 2. diencephalon a. thalamus i. relay for sensory and motor impulses to and from cortex b. hypothalamus i. hormonal signals ii. ANS iii. neuro-endocrine links iv. temp, satiety, thirst v. waking, sleeping 3. brain stem a. relay center b. midbrain i. cranial nerves c. pons i. cranial nerves ii. helps with breathing d. medulla i. consciousness, arousal ii. reflex centers - heartbeat, breathing, blood vessel diameter iii. swallowing, vomiting, coughing, sneezing, hiccoughing iv. helps with equilibrium v. cranial nerves 4. cerebellum a. coordinates skilled movements b. posture, balance B. cranial nerves C. spinal cord 1. meninges a. dura, arachnoid, pia 2. sensory tracts a. spinothalamic tracts b. posterior columns c. dermatomes i. skin bands innervated by posterior nerve roots 3. motor tracts a. pyramidal (corticospinal) b. extrapyramidal D. spinal nerve 1. posterior root a. sensory 2. anterior root b. motor 3. joins at intervertebral foramen 4. dorsal ramus a. deep muscles, skin of dorsum of trunk 5. ventral ramus a. lateral and anterior trunk b. extremities E. reflexes 1. fast, predictable, automatic responses to changes in the environment that help maintain homeostasis 2. somatic and visceral 3. reflex arc a. receptor b. sensory neuron c. integrating center i. one or more synapses and/or neurons d. motor neuron e. effector F. neurotransmitters 1. chemicals that cause signals to move across neuronal junctions 2. ACh - acetylcholine 3. amino acids a. GABA i. inhibitory b. glutamate c. aspartate 4. biogenic amines a. NE b. dopamine c. serotonin 5. neuropeptides a. largest category b. enkephalins c. endorphins d. substance P

History
A. OPQRST B. impact on patient’s life 1. ADL C. patient’s perceptions vs. those around him/her D. headache, fainting, blackouts, dizziness, clumsiness, seizures, convulsions, paralysis, local weakness, difficulty speaking, difficulty walking with coordination, tremors, numbness, tingling, difficulty with bladder or bowel control, trouble thinking, memory lapses, nervousness, irritability, depression, worrying, sleep, dreams, uncontrollable feelings E. frightened patient with a lot of subjective complaints F. localization of the lesion 1. muscle, nerve, spinal cord, brain G. ROS 1. neuro deficits common in systemic disorders H. family hx 1. metabolic & degenerative disorders inherited often I. social & travel 1. infectious causes

Physical
A. extent of neuro exam depends on hx, neuroanatomy & physiology B. often include in other parts of physical exam 1. mental with hx and general 2. cranial nerves with head and neck 3. PNS with peripheral vascular and musculoskeletal C. always do in a specific order so as not to miss anything D. mental status and speech 1. careful observation of patient’s behavior 2. demeanor, dress, grooming, hygiene 3. facial expression, manner, mood 4. speech, awareness, consciousness 5. orientation, memory, intellect, judgment a. time, place, person b. immediate recall, remote memory c. abstraction, knowledge, naming 6. full mental status exam a. specialized, lengthy E. cranial nerves 1. 1st - olfactory a. identify odors (coffee, soap, mint) to each nostril with eyes closed 2. 2nd - optic a. visual acuity, fields b. fundus 3. 3rd - oculomotor; 4th - trochlear; 6th - abducens a. PERRLA b. EOM 4. 5th - trigeminal a. 3 divisions - ophthalmic, maxillary, mandibular b. motor only in mandibular i. palpate clenched masseter c. sensory in all i. pinprick d. corneal reflex i. limbus with a wisp of cotton 5. 7th - facial a. watch face during conversation for asymmetries b. depressed nasolabial fold c. raise eyebrows, frown, close eyes tightly so cannot be opened, show teeth, smile, puff out cheeks d. taste to anterior 2/3 of tongue i. stroke side of tongue with sweet, sour, salty, or bitter 6. 8th - vestibulocochlear, acoustic a. hearing b. specialized tests for vestibular function 7. 9th - glossopharyngeal; 10th - vagus a. hoarseness b. gag reflex c. symmetric upward movement of soft palate and uvula on saying “ah” 8. 11th - spinal accessory a. palpate SCM while turning head against resistance 9. 12th - hypoglossal a. inspect tongue for atrophy, fasciculations, deviation i. deviates toward side of lesion when tongue is stuck out F. motor system 1. observe gait - watch patient walk down hall 2. inspect limbs and girdles for atrophy, asymmetry, fasciculations 3. walk heel to toe 4. walk on toes and then on heels 5. shallow knee bends unilaterally 6. Romberg sign 7. passive flexion and extension of limbs 8. muscle strength 9. coordination a. rapid rhythmic alternating movements i. pat leg fast with hand ii. rapidly turn hand over and back iii. touch each of fingers with thumb rapidly b. point to point testing c. heel on opposite knee and run it down shin G. sensory system 1. screening testing a. face, torso, 4 limbs b. pain, vibration in hands and feet c. light touch in arms and legs d. stereognosis 2. ability to perceive stimulus 3. symmetry - always do bilaterally 4. vibration and position sense distally a. if N, omit proximal 5. pain, temperature, touch both distally and proximally 6. cover most dermatomes and major peripheral nerves 7. meticulously map out boundaries of areas of hypo or hyperesthesia a. begin centrally at point of reduced sensation and move outward progressively until N 8. specific testing - done with closed eyes a. pain i. safety pin ii. sharp or dull - use point and dull end b. temperature i. tubes filled with hot and cold water ii. omit if pain N c. light touch i. cotton d. vibration i. low pitched tuning fork ii. dip of finger, ip of great toe iii. if impaired, more proximal bony prom e. position i. terminal phalanges of toes and fingers up and down ii. usually just great toe and index finger f. discriminative sensation i. stereognosis - identify object in hand ii. number id - draw number on palm iii. 2 point discrimination H. reflexes 1. DTR’s a. relaxed b. mild stretch on muscle c. strike tendon briskly 2. lateral differences 3. strength a. graded 0 - +4 b. hypo - lower motor neuron disease c. LMN - anterior horn cell, spinal root, peripheral nerve d. hyper - upper motor neuron disease e. UMN - motor cortex, brain stem, corticospinal tract down to LMN 4. biceps C5,6 5. triceps C7,8 6. brachioradialis C5,6 7. abdominal a. above umbilicus T8-10 b. below umbilicus T10-12 8. cremasteric (males) L1,2 9. patellar (knee, quadriceps) L2-4 10. ankle S1,2 a. if hyper, check for clonus b. rapid, rhythmic oscillations between dorsi and plantar flexion 11. plantar L4-S2 a. plantar flexion of toes b. Babinski’s sign - dorsiflexion of great toe with fanning of other toes i. upper motor neuron disease I. meningeal signs 1. if suspecting meningeal inflammation 2. Brudzinski’s sign a. pt supine, flex neck, watch for flexion of hips and knees 3. Kernig’s sign a. pt supine, flex one of hips and same knee, pain indicates meningeal inflammation or disc disease

Lab
A. none specific

Imaging
A. x-ray B. CT scan 1. cerebral sulci, ventricles, gray and white matter, bony structures C. MRI 1. brainstem, posterior fossa 2. demyelination, edema, syringomyelia

Special Studies
A. lumbar puncture 1. spinal tap 2. info about intracranial pressure and CSF 3. CSF usually clear, colorless a. blood, cell count, glucose, protein, stain, culture B. cerebral angiography C. myelography 1. x-ray of spinal cord after dye injected into subarachnoid space 2. abN within spinal canal D. PET scan 1. uptake of radioisotopes 2. blood flow, glucose, oxygen metabolism E. functional MRI F. SPECT scan G. electroencephalography (EEG) 1. recording of electrical currents in the brain 2. abnormal wave patterns, asymmetries, wave slowing H. electromyography 1. recording of electrical properties of muscle I. nerve conduction velocities 1. time for an impulse to travel a length of nerve

Emergencies
A. headache 1. may or may not be emergency 2. questions to ask yourself a. head trauma b. seizures c. acute onset d. rapidly changing pattern e. meningitis f. pg and hypertensive 3. if yes to any of the above questions, refer to ER 4. persistent hypertension with HA, refer to cardiologist 5. increasingly severe HA not responding to tx, refer to primary care provider B. vertigo 1. with HA or other CNS signs like diplopia, slurred speech, discoordination of an extremity, unilateral weakness all indicate central lesion a. refer for evaluation ASAP C. meningitis 1. acute bacterial meningitis 2. can be lethal in hours 3. uri 4. fever, HA, stiff neck, vomiting 5. purpural rash with above sxs indicates meningococcal meningitis 6. refer to ER immediately a. call ER and let them know pt is coming D. stroke 1. abrupt or gradual onset of neuro deficits 2. hypertension, DM, AS, embolism 3. possible referral to ER, primary care provider within that same day, 911 E. status epilepticus 1. seizures with no intervening periods of consciousness 2. 911