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PCM EX 2 > 6a. Approach to Neuro Cases II > Flashcards

6a. Approach to Neuro Cases II Flashcards

1
Q

What is a tremor?

A

involuntary, rhymic, oscilatory movement of body part

most common mvmt disorder seen in primary care

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2
Q

How are tremors classified?

A
  • resting
  • action
  • enhanced physiogic tremor
  • essential tremor
  • parkinsonism
  • cerebellar tremor
  • psychogenic
  • other: dystonic and wilson disease
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3
Q
  • occurs in body part that is relaxed and completely supported vs. gravity
  • enhanced by mental stress or movement of another body part (walking)
  • diminished by voluntary movement of that body part
A

resting tremor

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4
Q

What are the tyes of action tremors?

A
  • postural
  • isometric
  • kinetic
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5
Q

type of tremor: maintain a position against gravity

A

postural tremor

[ex: arm elevation]

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6
Q

type of tremor: musce contraction vs. rigid stationary object

A

isometric tremor

[ex: making a fist]

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7
Q

type of tremor: voluntary movement, including intention tremor (prduced with target-directed movement)

A

kinetic tremor

[ex: reaching for a pen]

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8
Q
  • low amplitude, high frequency at rest and during activity
  • enhanced by anxiety, stress, certain medications, and metabolic conditions
A

enhanced physiologic tremor

[note: everybody has an asymptomatic physiologic tremor]

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9
Q

When do patients with tremor not need any further testing?

A

“If a patient has a tremor that comes and goes with anxiety, medication use, caffeine intake, or fatigue, they do not need further testing.”

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10
Q
  • most common pathological tremor
  • 95% of patients have primarily kinetic rather than postural
  • most common in hands and wrists (also head, LE, voice)
  • bilateral and present w/ different tasks/interefers w/ many activities
  • can be inherited & progresses with age
  • 25% of those affected retire early or modify career path (can cause social embarassment)
    • can be exacerbated by caffeine and fatigue; can be helped by alcohol
A

essential tremors

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11
Q

How do medications cause Parkinsonism tremor?

A

blocking or depleting dopamine

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12
Q

Describe Parkinson’s Disease.

A
  • chronic neurodegenerative disease
  • most common form is idiopathic PD
  • 70% of PD pt w/ resting tremors
  • classic tremor = “pill rolling mtion”
  • bradykinesia = difficulty rising from seated position, reduced arm swing while walking, micrographia
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13
Q
  • low ferquency, slow-intension or postural tremor
  • typically caused by MS w/ cerebellar plaques, strokes, or brainstem tumors
A

cerebellar tremors

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14
Q

Cerebellar tremors are typically caused by ___.

A
  • MS w/ cerebellar plaques
  • strokes
  • brainstem tumors
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15
Q
  • can be difficult to differentiate from organic tremor
  • some features that are consistent include:
    • abrupt obset
    • spontaneous remission
    • changing tremor characteristics (location and freq)
    • increase with attention and extinction w/ distraction
  • more frequently seen in pt employed in allied health professions, involved in litigation
A

psychogenic tremors

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16
Q

What history should you obtain for tremor?

A
  • Fam hx of neuro disease or tremor = genetic component (esp essential tremor)
  • Age = tremor in older pt more likely PD or essential tremor
  • Onset = sudden onset more likely pschogenic (related to med use or toxin exposure or brain tumor - rare)
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17
Q

Distinguish between Parkinson’s Disease Tremor vs. Essential Tremor.

A
18
Q

Name history/signs consistent with Parkinson’s Disease.

A
19
Q

Name that tremor.

A

essential tremor

[large, tremulous, illegible]

20
Q

Name that tremor.

A

Parkinson’s Disease tremor

[small, can be ilegible]

21
Q

Define dementia.

A
  • loss of cognitive functioning (thinking, remembering, reasoning)
  • loss of behavioral abilities (interferes w/ daily life & activities)
  • functions lost: memory, language, visual perception, problem solving, self management, ability to focus and pay attn
22
Q

In what demographic is dementia more prevalent?

A

females (~82+ y/o)

23
Q

Name some etiologies of dementia.

A
24
Q

Which cognitive domain is affected based on these symptoms:

  • apathy
  • increase in inappropriate behaviors
  • loss of empathy
  • impaired judgment
A

social cognition

25
Q

Which cognitive domain is affected based on these symptoms:

  • difficulty in using familiar technology, tools, or kitchen appliances
  • getting lost in familiar environments
A

perceptual-motor

26
Q

Which cognitive domain is affected based on these symptoms:

  • forgetting ot buy items or buying same items multiple times at store
  • repetition in conversation
  • difficulty in recalling events
  • relying on lists of tasks to complete
  • forgetting to pay bills
A

learning and memory

27
Q

Which cognitive domain is affected based on these symptoms:

  • difficulty finding correct words
  • using general pronouns regularly instead of names
  • mispronunciation of words
  • problems w/ understanding verbal and written communication
A

language

28
Q

Which cognitive domain is affected based on these symptoms:

  • difficulty in completing previously familiar multistep tasks (preparing meals)
  • no longer wanting to participate in home activities
  • difficulty in completing activities or tasks b/c of easy distractablity
  • social outings become more taxing and less enjoyable
A

executive function

29
Q

Which cognitive domain is affected based on these symptoms:

  • normal routine tasks take longer
  • difficulty in completing tasks when multiple stimuli present
  • dfificulty in maintaining info while completing tasks (mental math, remember phone number to dial, etc.)
  • work requires more overview/rechecking than before
A

complex attention

30
Q

What is a major neurocognitive disorder?

(based on DSM-5)

A

significant cognitive decline in at least one domain interfering with activities of daily living

31
Q

What is a minor neurocognitive disorder?

(based on DSM-5)

A

modest cognitive decline that does not interere with daily living

32
Q

What should be included in history for dementia patient?

A
  • education (timeline of sx presentation and speed of progression)
  • med review (Beers criteria)
  • recent hospitalization (hx infection; delirium; cardiometabolic risk factors)
33
Q

What is important about the physical examination of a dementia patient?

A
  • exam is typically nrmal
  • exam intent is to look for reversible causes:
    • hypothyroidism
    • vitamin deficiencies
    • intracranial tumors
    • normal pressure hydrocephalus
    • depression
    • hypoperfusion from CHF
34
Q

Describe the brief initial screening test for cognitive impairment.

A
  1. mini-Cog
  2. ascertain dementia 8 item informant questionnaire
  3. general practitioner assessment of cognition
35
Q

Describe the mini-cog.

A
  • Pt asked to repeat 3 unrelated words, perform clock drawing test, then recall 3 works.
  • Sensitivity: (76-100%)
  • Specificity: (54-85%)
  • Scoring: 1 pt for each word remembered, 2 pt for good clock, 3-5 is lower likelihood for dementia but does not excluse some cognitive impairment
36
Q
  • screens for major and minor neurocognitive disorders
  • sensitivity 85%
  • specificty 86%
  • scoring: count # of “yes”
    • 0-1 = normal
    • 2+ = cognitive impairment likely
A

ascertain 8-item informant questionnaire

37
Q
  • patient and informant component
  • validation in primary care settng, little to no education bias, available in multiple languages
  • limitation: only in Australian populations
  • tests patient recall, clock drawng, information components
  • sensitivity 85%, specificty 86%
A

general practitioner assessment of cognition

38
Q

If the brief initial screening test for cognitive impairment is positive, what are the next steps?

A

Screening for Degree

  • MMSE
  • MOCA
  • St. Louis University Mental Status Exam
39
Q
  • most comonly used DEGREE screening
  • score. 0-30
  • sensitivity 81%, specificity 81% for dementia
  • nomograms for normal vs. impaired based on age
A

mini-mental state examination (MMSE)

40
Q
  • DEGREE screen designed for persons scoring 24 + on MMSE
  • accurate in patients with Parkinson’s disease
A

Montreal cognitive assessment (MOCA)

41
Q

If DEGREE screening is positive, what are the next steps?

A
  • geriatric depression scale to r/o pseudodementia
  • lab evaluation and neuroimaing for reversible causes of dementia

PCM EX 2 (11 decks)

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