T2 wannamaker neuro
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- 1. What are the proper levels of consciousness?
- Conscious or unconscious, Stimulus needed to awaken (Voice, Touch, Pain), Orientation (awareness of env - person, time, place); proper terminology - alert and oriented (x1,x2,x3)
- 2. Define Coma
- Unconsciousness, unresponsive to any stimuli. No voluntary movement. Deep: no reflex activity
- 3. Signs of dysphonia
- Dysphonia: voice disturbance due to larynx or its innervation (laryngitis, vocal chord paralysis = whisper
- 4. Signs of dysartria
- Dysartria: motor deficiency (words slurred, indistinct)
- 5. Describe Broca’s Aphasia
- Expressive (Broca's) Aphasia: Nonfluent, slow speech, Words meaningful, small words dropped, Spontaneous speech impaired
- 6. Describe Wernicke’s Aphasia
- Receptive (Wernicke’s) Aphasia: Speech: fluent, effortless, but sentences lack meaning
- 7. What are the pros of CT scan for CNS imaging?
- Pros CT scan: detects fresh hemorrhages; availability, quicker; lower cost; less restrictions v. MRI
- 8. What are limitations of MRI for CNS imaging?
- MRI contradindicated: pacemakers, ferrous foreign body. Relative contraindications: claustrophobia, non-magnetic metal artifact
- 9. What are the main indications and limitations for EEG?
- EEG Indications: Epilepsy/seizure (diagnosis, monitor response to therapy). EEG is NOT indicated to diagnoses brain death.
- 10. What is the criteria for brain death?
- No reflexes above foramen magnum level (including corneal, gag, and occulocephalic reflexes (dolls eyes)); No oculovestibular response; Pupils fixed (at 24hrs; Atropine, Epinephrine effect has worn off); Apnea off ventilator (oxygenation) 10min (pCO2 50+); No cerebral circulation; body temp > 34C (93F); No drug intoxication, paralyzing agents or anesthetics
- What are clinical indicators of increased intercranial pressure (ICP)?
- Clinical manifestations: bradycardia, hypertension, hyperventilation.
- What are medical treatments for increased ICP?
- Intubation, mechanical ventilation with hyperventilation (short term effect). Preserved renal function vital: Mannitol which acts as osmotic agent to draw fluid “off brainâ€, and consider Furosemide (Lasix) to enhance diuresis. For patients with increased ICP due to malignancy, use Dexamethasone (corticosteroid)
- What long term risks are associated with coma?
- Decubitis ulcers (bed sores); aspiration pneumonitis/ pneumonia risk; Deep vein thrombosis/ Pulmonary emboli
- What symptom would you see in a coma patient induced by narcotic/opiod overdose? How would you treat them?
- Pinpoint pupils. Tx Naloxone (Narcan)
- What would the differential diagnosis be of coma with fever?
- Infection (urinary tract infections, pneumonia, or bacterial meningitis); heat stroke (loss of ability to sweat; indicator is dry skin); rarely, lesion affecting temperature regulatory center (bad prognosis)
- Explain the course of hepatic encephalopathy.
- Severity of symptoms corresponds to Ammonia level, but fall in ammonia level precedes clinical improvement.
- What would be precipitators of hepatic encephalopathy?
- Precipitating factors: increased dietary protein, upper GI bleeding, constipation, sedative – hypnotic medications.
- How would you diagnose hepatic encephalopathy?
- Develops over days to weeks. Symptoms: confusion, drowsiness, and coma. May not be reversible. Reason to test for ammonia levels (blood flow is shifted around liver +/- liver is diseased, ammonia is not converted to urea.
- How would you diagnose and treat hypertensive encephalopathy?
- Symptoms include severe headache, nausea with vomiting, visual disturbance, confusion, coma. Exam findings: retinal hemorrhages, papilledema. Treatment: Nitroprusside
- Describe the use and components of the Glasgow Coma Scale (GCS).
- Assessment tool for coma patient (scale 3-15) = eyes open (1-4) + verbal response (1-5) + motor response (1-6)
- What is the most common symptom of Acoustic Neurinoma?
- Unilateral sensorineural hearing loss
- What is the cranial nerve involved in Acoustic Neurinoma?
- A benign tumor, Schwann cell of the superior vestibular division of 8th cranial nerve.
- Describe ataxic gait?
- Frankenstein-like movements: legs widely apart and extended, arms extended in compensatory balance, short steps, look at ground for additional sensory input.
- What are common properties, symptoms and physical findings of Friedreich’s ataxia?
- Most common type of hereditary ataxia. Ataxia begins in childhood and progresses (Ataxia > Areflexia > Babinski sign before 25). Mean age of death at 37yo. Most common cause of death: Heart failure. Interstitial fibrosis leads to ventricular hypertrophy.
- How would you differentiate weight-bearing from non-weight bearing components of the spinal column?
- Weight-bearing: Intervertebral Disc, vertebral body anteriorly; Non-weight-bearing: vertebral arch, spinous process, transverse process
- Explain the physiology of extension of the spine
- Extension of the spine reduces the size of the intervertebral foramen
- Define Radicular Pain
- Radicular Pain: Cutaneous distribution of compressed nerve root (ie. Sciatica)
- Where does osteoporosis vertebral fractures occur?
- Osteoporotic fractures and Tumors typically occur in the thorax
- What is the classic pain description of spinal canal stenosis?
- Spinal Canal Stenosis: Worse with walking, especially up an incline (slight flexion of spine)
- How would you assign grade to muscle strength?
- Muscle Strength: 5/5: Normal Strength, 4/5: Active Power (deconditioned), 3/5: Power to overcome gravity, but not resistance, 2/5: Movement, not against gravity, 1/5: Muscle Contraction, 0/5 No movement, contraction
- What is the dermatome of nipple and umbilicus?
- Nipple – T4 dermatome; Umbilicus – T10 dermatome (L2/3 Vertebral Level)
- How would you recognize a good quality lateral C-spine x-ray?
- Good Lateral Cervical Spine X-Ray: must include all 7 vertebrae and C7/T1 junction
- What is the definitive imaging study of the spinal cord?
- MRI is definitive study for the Spinal Cord
- How would you assess thoracic motor function?
- Recognize lack of ability to assess thoracic motor function, especially compared to cervical and lumbar. Only T1 – Hand intrinsics – finger ABducion.
- What is typical position of acute spinal cord injury?
- Most Devastating injuries occur with neck flexed – “Keep your head upâ€
- How would you "clear" a spine clinically?
- Clinically Clearing the spine in a Pt with no neurological deficits. Alert, oriented patient; No alcohol; No narcotics, hallucinagens, sedatives; No distracting injuries (ie. major fracture)
- What spinal level innervates the diaphragm?
- Diaphragm is innervated by C4
- What pharmacological treatment would be used for acute injury?
- Pharmacological Therapy for Acute injury: Methylprednisolone (Solu-Medrol) – Anti-inflammatory Steroid
- What classes of medicines are used to prevent stress ulcers?
- Medicine to reduce risk for stress ulcers (caused by low blood flow & steroids): raise pH in stomach. Antacids, Sucralfate (Carafate), Histamine (H2) blockers, Proton Pump Inhibitors (PPI)
- What are the risks for urinary tract infections in chronic spinal cord injury pts?
- Neurogenic Bladder (20% risk, each year); Lack of reflex bladder contraction when filled; Urinary retention; Self catheterization; Chronic indwelling foley catheter or suprapubic catheter
- What are typical agents used to treat spasticity?
- Typical Agents used to treat spasticity (caused by UMN): Antispasmotic: Baclofen, Benzodiazepine: Diazepam (Valium), Dantrolene, Clonidine (Catapress),
- What are methods for prevention and treatment of decubitis ulcers?
- Prevention and Treatment of Decubitis Ulcers: Frequent turning / repositioning, q 24 hours; Cushioning; Barrier products, ie. Creams, artificial skin; Moisture protection; Good nutrition; Good circulation
- What are the four cardinal signs of parkinsonism?
- tremor at rest, bradykinesia (slow low movement), rigidity, postural instability (falls)
- What are the pathologic findings in Parkinson's disease?
- Parkinson's disease - pathologically, depigmentation of Substantia Nigra and Lewy bodies; Substantia Nigra - loss of dopaminergic neurons, Lewy bodies - eosinophilic cytoplasmic
- How would you diagnose Parkinsonism?
- Average age: 55. 60+ years of age: 1% prevalence, Men: Women 3:2, clinical diagnosis: resting tremor (tremor goes away with movement or intention)
- How would you diagnose Huntington's Chorea?
- chorea - continuous irregular jerklike movement, Dementia, Psychiatric disturbances, Peak onset: 4th and 5th decade (30s, 40s)
- How do you recognize and treat medication induced dystonia?
- Involuntary, spasmodic muscle twitching causing abnormal postures (i.e. torticollis) (self-limiting), Common cause: dopamine receptor blocking drugs, i.e. Chlorpromazine (Compazine); Treat with Diphenhydramine (Benadryl)