Clinical Assessment of the Neurosurgical Patient’ Flashcards
What is the point in doing a history/exam?
- Anatomical Localisation……where is the lesion?
- Causative Pathology…..what is the problem?
- Effect on Daily Life…..how it effects the patient day to day?
WHat should be found when assessing a patient?
- Pick up on cues
- Explore anatomically adjacent areas
- Probe inconsistencies
- Don’t finish the encounter with a story that doesn’t make sense to you
What questions should you ask yourself in regards to a patients management?
- Are special tests required?
- Which ones?
- What can I do to help this patient?
- How quickly do we need to act?
Who would you get a histroy from when dealling with a unconscious patient (A+E/roadside) and what tests would be done?
History from paramedics/bystanders
GCS, pupils
Who would you get a histroy from when dealling with a patient who is confused/dysphasic/preverbal patient (ward) and what tests would you need to carry out?
History from family/notes
Posture, neglect, mini-mental
Who would you get a histroy from when dealling with an awake and alert patient (ward/clinic)and what tests would you need to carry out?
History from patient
Focused neuro-exam
WHat tests are done for unconscious patients and what may be the cause?
ABC
GCS
Pupils
Cerebral perfusion/metabolic
Cerebral herniation
Why may the pupils dilate in herniation?
Brain can be pushed under the falx cerebri and the brain can so be pushed below the tentorium cerebelli and if it herniates over the tent then it presses on the 3rd nerve resulting in dilation
What tests do you do in a non communicative Patient?
Observation – posturing, focal lack of movement, neglect, eye movements
Assess speech
Mini-mental score
What do you need to think about when dealling with a communicating Patient?
Cranial - which lobe, cerebellar, CN?
Spinal - which level, myelopathy, radiculopathy,
Peripheral nerve
Is cerebral localisation important?
yes
What are the functions of the forntal lobe?
Voluntary control of movement - precentral gyrus
Speech – pars opercularis, pars triangularis
Higher order - Restraint, Initiative, and Order (RIO)
What are the higer order functions of the frontal lobe?
Restraint, Initiative, and Order (RIO)
Restraint - Mediates empathic, civil and socially appropriate behaviour
What is involved in an examination of the frontal lobe?
• Inspection
- Decorticate posture
- Altered behaviour
- Abulia
• Pyramidal weakness
- UMN signs – weakness, increased tone, brisk reflexes, up-going plantar
- Pronator drift
• Speech
What are the 2 speech areas of the brain?
inferior frontal gyrus, area known as brocas area which is responsible for motor and expressive point of speech. IT is involved in the expressive aspects of spoken and written language (production of sentences constrained by the rules of grammar and syntax)
Wernicke’s area is the region of the brain that is important for language development. It is located in the temporal lobe on the left side of the brain and is responsible for the comprehension of speech, while Broca’s area is related to the production of speech
What is involved when examining language?
Ensure hearing is intact and patient’s first language is English
Handedness - want to know what hand the patient writes with
Fluency – Broca’s
Nominal aphasia - a mild, fluent type of aphasia where individuals have word retrieval failures and cannot express the words they want to say
Repetition – arcuate fasciculus
3 step command – Wernicke’s
‘Baby hippopotamus’ – cerebellar speech
Orofacial movement – ppp, ttt, mmm
Reading
Writing
What is the arcuate fasciculus?
The arcuate fasciculus (Latin: curved bundle) is a bundle of axons that connects Broca’s area and Wernicke’s area in the brain
What is the difference between the 2 parietal lobes?
one is dominant and one is non-dominant
How do you examine the dominant parietal lobe?
Dominant side:
- Dyscalculia - difficulty in understanding numbers
- Finger anomia
- Left/right disorientation
- Agraphia - loss in the ability to communicate through writing
How do you exmaine a non dominant parietal lobe?
- Ideomotor apraxia
- ‘How to do’ – light a match
- Ideational apraxia
- ‘What to do’ – loss of understanding of the purpose of objects – what is a comb for?
- Constructional apraxia
- Dressing apraxia
- Hemineglect
- Loss of spatial awareness
apraxia - difficulty with the motor planning to perform tasks or movements when asked
What are the functions of the temporal lobe?
- Processes auditory input (Heschl gyrus)
- Language
- Encoding declarative long-term memory (hippocampus) – semantic/episodic
- Emotion (amygdala)
- Visual fields (Meyer’s loop)
study this image
What is the lateral geniculate nucleus?
a relay center in the thalamus for the visual pathway
it receives a major sensory input from the retina
What problems may arise form the cerebellum?
- Dysdiadochokinesia - medical term for an impaired ability to perform rapid, alternating movements
- Ataxia - a group of disorders that affect co-ordination, balance and speech
- Nystagmus
- Intention tremor
- Slurred Speech
- Hypotonia - state of low muscle tone, often involving reduced muscle strength
- Past pointing - if the eyes are closed, a pointing finger overshoots its intended mark towards the side of the cerebellar damage
What are the different problems that may be seen in the spine?
Does it fit with nerve root (radiculopathy)? – unilateral, single myotome, single dermatome, (reflex), LMN
Does it fit with peripheral nerve? – unilateral, motor and sensory deficit fits with PN, LMN
Does it fit with cord (myelopathy)? – bilateral, motor and sensory level, UMN (long tract signs)
Does it fit with peripheral neuropathy? – glove and stocking distribution
Is it actually higher? Brain stem/hemisphere
What is a myelopathy and what does it cause?
an injury to the spinal cord due to severe compression that may result from trauma, congenital stenosis, degenerative disease or disc herniation
Cervical or thoracic pathology
Motor and sensory level
UMN below lesion
Long tract signs – clonus, upgoing plantars, increased tone, Hoffman sign, brisk reflexes, proprioception impairment – Romberg’ test, tandem walking
What is Radiculopathy?
one or more nerves are affected and do not work properly
Pain in single dermatome
Dermatomal sensory disturbance
Weakness in myotome
Loss of reflex
What is dysphasia?
language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage
