Module 10

Question 1

Seizures

Answer 1

• What is a seizure?
  
  • A brief disruption in the brain’s electrical functions
• Convulsion
  
  • Jerky, contract-relax (tonic-clonic) movement
• Epilepsy
  
  • A condition which no underlying correctable cause for the seizure can be found
  • Seizure activity recurs
  • 5-10 per 1000 have epilepsy
• Lots of causes of seizures
• Short circuit of electrical activity in brain: can be local or generalized which can determine how
• Two generalized types of movements tonic movement sustained contraction clonic movements is?

Question 2

Seizures

Answer 2

• Normal neuronal function
  
  • intact brain tissue
  • functional nervous system
  • right amount of neurotransmitters
• Can range anywhere from
  
  • appearing to “daydream” to forceful contractions and unconsciousness
  • occur during the day or even at night while the patient is sleeping
• Severity of the seizure depends on the origin or extent of the dysfunction.
  
  • Isolated instances of seizures or if they are due to a specific cause such as a high fever or hypoglycemia are termed seizures.
  • Recurring seizures are identified as an epilepsy disorder.
• “Aura”

Question 3

Neurons

Answer 3

• Billions of neurons transport messages to and from the brain
• Need the help of neurotransmitters
• Outcomes of these transmissions are an action that can be stimulating (epinephrine) or inhibiting (GABA).

Question 4

Nerve transmission

Answer 4

• Afferent sensory impulses are carried from the dorsal horn of the spinal nerves into the CNS
• Encounter a “relay” station such as the thalamus located in the midbrain
• Once a particular action is determined, efferent nerve impulses travel to the ventral horn of the spinal nerves and cause a motor reaction.
• Hence, massive overstimulation can cause forceful muscle contractions.

Question 5

Seizure Classification

Answer 5

• Clinical manifestation
• Site of origin
• EEG correlation
• Response to therapy
• This is a broad classification of seizures
  We are going to go over partial and generalized seizures, the ones that are circled

Question 6

Partial seizures

Answer 6

1) Simple Partial

2) Complex Partial

Question 7

Generalized Seizures

Answer 7

1) Absence

2) Tonic-Clonic

Question 8

Tonic- Clonic Seizures

Answer 8

• Grand mal seizures
• Abnormal electrical activity involves both brain hemispheres
• Causes the most physical symptoms such as stiffening (tonic) and jerking (clonic), loss of consciousness, depressed respiratory function, tongue biting and often loss of bodily functions
• Episode can last from seconds to several minutes
• Post-ictal period, that may last minutes to hours - ALOC
• Contrary to what is shown in movies often, nothing should be put into the person’s mouth. Any objects around the patient should be moved to avoid injury (jerking motions) and the patient should be rolled to the side to prevent choking, aspiration and loss of airway.
• This is a generalized type of seizure
• Entire brain
• May or may not feel the seizure coming on
• A person can not swallow their tongue, you turn them over if they are vomited, bleeding, saliva that can block the airway
• Don’t stick anything in their mouth

Question 9

Phases of a “Tonic-Clonic” seizure

Answer 9

1) The “Aura” Phase: light headedness, dizziness, confusion, hallucinations
2) The “Tonic” phase: skeletal muscles tense up, jerky movements, usually lose consciousness
3) The “Clonic” Phase: Convulsions, violent shaking, uncontrollable twitching/rolling, sometimes breathing stops
4) Postical sleep: Confusion, amnesia, and nausea upon regaining consciousness

Question 10

Absence Seizures

Answer 10

• Petit mal
• Person appears to be “daydreaming.”
• Usually has no prodromal period, loss of consciousness or post-ictal period
• Usually last 10-20 seconds and the person has full awareness after the seizure, but not on what has transpired during the seizure. If you attempt to speak to this person during the seizure, you will not get a response as compared to daydreaming.
• This often is seen in children and can occur several hundred of times per day if severe.
• Type of generalized seizure
• This is more of a cognitive change
• No prodromal period so there is now warning
• They don’t lose consciousness but you still can’t communicate with them

Question 11

Simple Partial Seizure

Answer 11

• Usually due to an isolated impulse in the brain
• A simple partial seizure may go unnoticed by others or shrugged off by the sufferer as merely a “funny turn“
• Start suddenly and are very brief, typically lasting 60 to 120 seconds
• Affects (depends on where the overstimulation is in the brain)
  
  • motor (jerking, head turning, vision/hearing/speech impairment i.e. labored speech or inability to speak at all)
  • sensory (unusual sensation for example – you are sitting at your desk and all of a sudden smell burning toast)
  • autonomic (change in vitals signs or body temperature)
  • psychological (sudden and inexplicable feelings of fear, anger, sadness, happiness or nausea. Some patients describe a feeling of déjà vu)
• Consciousness is maintained and usually the event is remembered in detail
• Can progress into a complex partial or generalized seizure if the abnormal brain stimulus is propagated to other areas of the brain and consciousness may be lost.
• This is a partial seizure which referrs to a portion of the brain
• Depending which region is affected with determine what a person experiences
• Usually a person doesn’t lose consciousness
• Out of the blue changes in mood
• Can generalize which means they can get worse in turn into a complex seizure or a

Question 12

Complex Partial Seizure

Answer 12

• Originate in any lobe of the brain
• Often preceded by a seizure aura (usually a simple partial seizure)  a feeling of déjà vu, jamais vu, fear, euphoria or depersonalization, visual disturbance (tunnel vision or a change in the size of objects)
• If you address the person, you will not get a response
• Impaired awareness (the person may still be able to perform routine tasks such as walking, although such movements are not purposeful or planned)
• Often accompanied by automatism
  person may make chewing, lip smacking, picking or other non-purposeful involuntary motions
• Can last up to several minutes
• May have a post-ictal period for minutes to hours
• Can affect anyone, but is often seen with some type of brain injury such as trauma or infection
• Can progress to a tonic-clonic seizure
• They have a aura or a warning
• That aura could be a simple partial seizure
• Jamais vu is a feeling of pre-something

Question 13

Depression

Answer 13

• Signs and Symptoms
  
  • Sadness, apathy, weight/appetite changes, decreased energy, suicidal thoughts
  • Mood swings, insomnia, crying
• Depression – children, adults, elderly
  
  • Major – interferes with life – job, family, sleep, eat, study
  • Adolescents – hard to diagnose – changes from “normal” (include anxiety, anger and avoidance of social interaction)
• Post- Partum > > “baby blues”
  
  • S/S + intense anger, severe mood swings, thoughts of harming self or baby
  • Post-Partum Psychosis > confusion, hallucination, paranoia, attempting to harm self or baby
• Seasonal Affective Disorder
  
  • Onset in fall/winter
• Dysthymia
  
  • Less severe than major depression > 2yrs
• Causes
  
  • NT deficiency, situational, drug induced
• Testing
  
  • Psychological testing - SIGECAPS
  • Diagnostic and Statistical Manual of Mental Disorders
    
    • American Psychiatric Association
• Tx
  
  • Therapy, Meds
• There is situational depression from normal life events there is no pharmological Tx
• Post-partum depression
• Seasonal effective disorder is
• NT is a neurotransmitter deficiency
• SIGECAPS is the cartoon photo
• Is there a valid reason
• Can go hyperphasia or hypo
• Psychomotor function is slowing down mentally not necessarily physically
• Suicidal ideations is with or without a plan
• You have to have 4 of those every day for 2 weeks (photo depression assessment)

Question 14

Schizophrenia

Answer 14

• “Chronic, severe and disabling brain disorder”
• Causes
  
  • Familial
  • Genetic + Environmental
• Signs and Symptoms
  
  • Hallucinations – auditory, visual, tactile
  • Beliefs of others can hear their thoughts – paranoia
  • Onset 16-30, typically NOT after 45
  • Rarely starts in childhood, but can happen
• Testing
  
  • Clinical
  • R/O other “physical” causes – drug abuse
• There are different causes, familial (family)
• You see a lot in homeless population
• Usually earlier in life onset
• Antipsychotics treatment
• Patrick star case study photo

Question 15

Wernicke - Korsakoff SyndromeWernicke encephalopathy

Answer 15

• Loss of brain function due to thiamine (Vitamin B1) deficiency
  
  • Also called “Wet Brain “ due to association with alcoholism
  • 0.4% to 2.8% of reported autopsies – under reported?
• Causes
  
  • Alcoholism – interferes with B1 absorption
  • AIDS
  • Weight loss procedure?
  • Hyperemisis gravidarum – extreme N/V
• Signs and Symptoms
  
  • Confabulations – make up info they can’t remember
    
    • Pts believe what they are saying – Not lying
  • Visual (nystagmsus), coordination and memory changes
  • Problems with making new memories
• Testing
  
  • Decreased Thiamine
  • Liver function test – help confirm alcoholism
  • Pregnancy test
  • TSH, T3, T4
  • MRI may show brain tissue changes, but usually is not needed
• Tx
  
  • High dose of B1 – stops destruction, but no reversal of damage
• Confabulations is different than lying. They believe what they say to be true
• Problems making new memories is called anterograde amnesia
• Check thiamine level for testing
• Make sure it’s not a thyroid issue
• Jack baur photo of the case study

Question 16

Thiamin helps produce?

Answer 16

Thiamin helps produce energy needed to make neurons function properly. Insufficient thiamin can lead to damage or death of neurons.

Question 17

Stroke AKA “Brain Attack”

Answer 17

• Decreased blood flow to brain
• Causes
  
  • Ischemic – Thrombus/ Embolus
  • Hemorrhagic – dissected aneurysm, subarachnoid hemorrhage, AVM
    
    • Arteriovenous malformations
  • TIA -

Question 18

Signs of stroke

Answer 18

S = Speech, or problems with language
T = Tingling, or numbness in your body
R = Remember, or problems with thinking
O = Off-balance, or problems with coordination
K = Killer headache
E = Eyes, or problems with vision

Question 19

Parkinson Disease

Answer 19

• Degenerative disorder, depletion of dopamine resulting in hypertonia (tremor & rigidity) and akinesia.
• Loss of substantia nigra dopamine-producing neurons; excess cholinergic activity in basal ganglia
• S/S
  Onset 40+, peaks around 58-62
  M>F *40,000 new cases per year in US
  Resting tremor
  Rigidity
  Bradykinesia / akinesia
  Stooped posture
  Shuffling gait
  Disequilibrium
  Muffled/slurred speech, diminished facial expression
  Dementia – more common in pts over 70 yrs old
• Degenerative region of brain that controls movement
• Masked faces is diminished facial expressions
• Shuffling gait they have a hard time initiating movement
• Bradykinesia is slow movement
• Later on dementia will set in usually in elderly

Question 20

Basal Ganglia’s Role in Parkinson’s Disease

Answer 20

• STN releases dopamine to other areas of?
• Dopamine normally stimulates direct pathway, when there is dopamine around it tells that person to move & allows them to have controlled intinital movement
• Dopamine also inhibits indirect pathway
• Not enough dopamine around turns of direct pathway so people will move less
• Decrease dopamine also turns on indirect pathway
• Dopamine stimulates the DIRECT pathway!
• Dopamine inhibits the INDIRECT pathway!
• Decreased dopamine levels turns off the DIRECT pathway
• Decreased dopamine levels turns on the INDIRECT pathway

Question 21

Parkinson Disease – Levadopa Tx

Answer 21

Levodopa is converted to dopamine via the action of a naturally occurring enzyme called DOPA decarboxylase. This occurs both in the peripheral circulation and in the central nervous system after levodopa has crossed the blood brain barrier. Activation of central dopamine receptors improves the symptoms of Parkinson’s disease; however, activation of peripheral dopamine receptors causes nausea and vomiting. For this reason levodopa is usually administered in combination with a DOPA decarboxylase inhibitor (DDCI), in this case carbidopa, which is very polar (and charged at physiologic pH) and cannot cross the blood brain barrier, however prevents peripheral conversion of levodopa to dopamine and thereby reduces the unwanted peripheral side effects of levodopa. Use of carbidopa also increases the quantity of levodopa in the bloodstream that is available to enter the brain.

• Tx give them dopamine
• Read this to see how dopamine works
• If you give some a dopamine pill or shot it can’t cross the blood brain barrier
• Astrocytes from the blood brain barrier
• Levodopa can cross the blood brain barrier, it still needs to be converted to dopamine. The enzyme DDC converts levodopa to dopamine you need dopamine in the brain
• You give a second drug carbidopa which blocks
• You want more dopamine in the brain

Question 22

What Is Consciousness?

Answer 22

A clear state of awareness of self and the environment in which attention is focused on immediate matters, as distinguished from mental activity of an unconscious or subconscious nature.

Question 23

Assessing Level Of Consciousness

Answer 23

A- Alert
V- Verbal command/stimuli
P- Pain stimulus
U- Unconscious/unresponsive

• Only alert state is normal

Question 24

Assessing Level Of Consciousness

Answer 24

• Created in 1974 at the University of Glasgow
• Most widely used method for reporting serial neurological examinations
• 3-8 score - considered in a coma
• Don’t need to memorize the glasgow coma scale
  If someone is living the worst score they can get is a 3
  0 means dead
  3-8 is considered in a coma

Question 25

Assessing Level Of Consciousness

Answer 25

• Consciousness is at the cerebrum level in the brain
• Loud sound can wake you, movement, light, pain, smell doesn’t wake you up but smelling salts do because they burn your mucosa?
• You can look at someones pupil to determine what might be going on in someone’s brain
• Sympathetic response makes pupils get bigger? Check
• Norepineprhine Alpha 1 causes what?
• Parasympathetic causes pupil to get smaller
• Only neurostransmitter of the ____ is Ach
• Two muscles in the eye iris constrictor and iris dilator muscles
• Which cranial nerve carries?
• Know cranial nerves and what they do
• Be able to answer the question in pathophys warm up about the eyes, the constrictor and dilator muscles.
• Pain killers will make pupils small (pin point pupils) opiates have a side effect of hitting the M3 receptor in the eye.
• Opiates have a parasympathetic side effect
• Opiates slow intestinal movements
• Normal Pupil size is 3-5 mm in diameter

Question 26

Impaired Consciousness

Answer 26

• Maintaining alertness requires intact function of the cerebral hemispheres and preservation of arousal mechanisms in the reticular activating system (RAS).
• RAS - an extensive network of nuclei and interconnecting fibers in the upper pons, midbrain, and posterior diencephalon.

Question 27

Reticular Activating System (RAS)

Answer 27

An extensive network of nuclei and interconnecting fibers in the upper pons, midbrain, and posterior diencephalon.

Question 28

Reticular Activating System (RAS)

Answer 28

• One interesting thing about the RAS is that it responds to stimuli except for smell. Smell won’t cause activity in the RAS. Some ask “then why will smelling salts bring someone back to consciousness”.
• Its not because of the smell but because the smelling salts burn and irritate the nasal mucosa. Fire alarms need noise and light to wake us because the smell of smoke alone will not stimulate the RAS.

Question 29

Coma

Answer 29

• State of altered arousal characterized by extreme unresponsiveness from which patient cannot be aroused and absence of voluntary movement
• Mechanism - bilateral cerebral hemisphere involvement or RAS dysfunction
• Caused by:
  
  • Structural disorders (result in focal damage): tumor, abscess, hemorrhage, hematoma, concussion
  • Non-structural/metabolic factors (result in diffuse damage): DKA, hepatic encephalopathy, hypercalcemia, hypercapnia, hypoglycemia, hyponatremia, hypoxia, myxedema, uremia, infxns, hyper/hypothermia, sedative OD
• Clinical Dx - Glasgow Coma Scale
• Many things can cause coma, some are very obvious
• Non-structural means you don’t damage the brain tissue
• DKA their blood sugar will be high (300 or 400)
• Hypercapnia is too much CO2, why might someone be like this in a coma?
• Hypoglycemia is low blood sugar,
• Someone who is diabetic and is unconsiouce how do you help?

Question 30

Acute Confusion

Answer 30

• Acute Confusion (i.e. Delirium)
• Causes
  
  • Acute infections
  • Drug/Medication induced (polypharmacy)
  • Vascular
  • Metabolic
  • Deficiencies
  • Endocrine
  • Post surgery – esp. elderly
  • Stress, New environment
• Signs and Symptoms
  
  • Acute, transient confusion, disorder of attention
• Testing
  
  • Clinical
• Delirium is acute transient and it can come and go
• Polypharmacy is lots of medications
• Vascular problems could be in the brain or trauma (from losing blood), or slowly losing blood from GI tract
• Think of the endocrine problems that can cause acute delirium

Question 31

Dementia

Answer 31

• Causes
  
  • Alzheimer’s disease
  • Huntington’s disease
  • Not normal part of aging
• Signs and Symptoms
  
  • Progressive failure of cerebral functions
  • Confusion
  • Memory loss
  • Loss of reasoning and judgment
• Testing
  
  • CT/MRI
  • R/O all other physical/mental causes
• Dementia is irreversible

Question 32

Alzheimer’s Disease

Answer 32

• Progressive destruction of the brain
• Main cause of dementia in elderly
• Causes
  
  • Suspected genes (chromosome 21)
  • FHx
  • NOT Aluminum
• Signs and Symptoms
  
  • Amyloid plaques
  • Neurofibrillary tangles
  • Problems > memory, judgment, behavior, reasoning
  • > 65 yr old
  • Inc incidence: head trauma, low education, Down’s
• Prevention: healthy aging, intellectual stimulation, social activity
• Testing: mental status exams & CT/MRI to R/O other causes
• Number one cause is age
• Some genetic inheritence
• Can’t cure alzheimers can only manage the symptoms
• Short term memory is the first thing to go
• Later on in the disease is judgment and so on
• Work out your brain, use it or lose it
• No cure for alzheimer’s disease, it has surpassed cancer in terms of what people are afraid of getting

Question 33

Alzheimer’s Disease

Answer 33

• Alzheimer tissue has fewer synapses and neurons
• Beta Amyloid plaques between cells
• Neurofibrillary Tangles of twisted strands of protein
• Cortex shrinks
• Hippocampus shrinks
• Ventricles enlarge
• Brain atrophy in advanced alzheimer’s disease

Question 34

Huntington’s Disease

Answer 34

• Progressive degeneration of nerve cells; loss of GABA neurons (inhibitory) within basal ganglia
• Causes
  
  • Genetic- Autosomal dominant (Chromosome 4)
  • 30-50 year old onset
• Signs and Symptoms
  
  • Chorea(athetosis) > Irregular, spasmodic, involuntary movements (face, limbs, whole body), twisting and writhing; hyperkinesia
  • Dementia: executive attention deficits, bradyphrenia (slowed thought process), mood
  • Problems > Speech, Balance, Swallowing
• Testing
  
  • CT/MRI (caudate nuclei atrophy), Genetic testing
• Brush up on neuro anatomy of the brain
• Basal ganglia is one of regions of brains helps to regulate movement
• There are issues with different regions of basal ganglia for this disease
• Need to know genetics for this one
• They do know the gene and exactly where on the gene it is.
• This is a movement disorder
• Involunatary hyperkinesia (excessive movement)
• There is genetic testing that you can perform
• Review basal ganglia structure: know thalmus the hippocampus, different neuclei
• Enlargement of brain structures with this disease

Question 35

Huntington’s Disease

Answer 35

• 5 in 100,000
• Most patients survive w/disease for 10-25 years after onset
• Pneumonia & CV disease were the main cause of death
• Mean age of death is 51-57
• HD gene - CAG repeats indicates HD risk
• HD gene you look for repeats of nucelic acid bases, the more repeats=more likely they will get HD

Question 36

Huntington’s Disease
Normal results
“Gray zone” results

Answer 36

• Normal results CAG= Less than 27. People with this result are not at risk of developing HD, nor are their children
• Gray zone results CAG= 27-35. People with this result are not at risk of developing HD themselves, but their children may still be at risk of inheriting an abnormal gene and developing HD

*Greater than 40 the person is at very high risk of getting HD
Autosomal dominant means you only need one bad copy of the gene

Question 37

Basal Ganglia’s Role in Huntington’s Disease

Answer 37

• Early in the disease, the D2 receptors involved in the INDIRECT pathway get destroyed – chorea (jerky, writhing, involuntary movements affecting especially the shoulders, hips, and face) results
• Later in the disease the D1 receptors in the DIRECT pathway get destroyed as well – bradykinesia (diminished movement results
• Frontal slice of the brain
• Several regions in here: primary motor cortex, basal ganglia is everything else which is a collection of structures
• Two major pathways for basal ganglia: direct & indirect pathway
  Issues with HD is with both pathways
• D2 are dopamine receptors
• Normally dopamine inhibits the indirect pathway which inhibits movement
• If your indirect pathway is firing your indirect pathway the person is moving less
• The neurotransmitter that fires up that indirect pathway is dopamine which inhibits the indirect pathway
• HD disease more dopamine means you move more
• Early in the disease the D2 receptors gets destroyed so early in the disease the person moves more because you are removing the inhibition (the breaks)
• Later on in the disease you get destruction of D1 receptors. The direct pathway enables movement so the person wont be able to move as much

Question 38

Urinary Tract Infection (UTI)

Answer 38

• Infection common cause of confusion in elderly; UTI is a common infection
• Causes
  
  • Cystitis – E. coli (Bladder infection)
  • Pyelonephritis (kidney)
  • Increased in females, DM, urinary catheters, poor hygiene, dehydration, compromised immune system
• Signs and Symptoms
  
  • Dysuria, frequency, urgency, fever, flank pain, N/V
    Hematuria, leukocytosis
• Testing
  
  • UA, Urine (Culture)
• UTI especially in elderly can be a major cause of short term confusion
• Usually E coli
• 30% of fecal matter is E coli
• How does E coli get to urethra? Improper hygiene or sexual intercourse
• There is an increase in females because the urethra is linked by 1 inch to the anus
• Catheters are a great place for things to colonizegrow
• Number one risk occupation is a teacher because they hold in their urine more often
• The frequency & urgency: anytime the bladder wall is irritated the urgency : infection is causing inflammation it doesn’t mean a person is producing more urine it just means the bladder wall is more irritated

Question 39

Hypoglycemia

Answer 39

• Decreased blood glucose
• Causes
  
  • Not eating
  • DM (Insulin shock?)
  • Alcoholism
  • Hepatitis
  • Endocrine tumor
• Signs and Symptoms
  
  • Hunger, cold/clammy, HA, anxiety, arrythmias
• Testing
  
  • Blood glucose – Fasting and 2 hour Postprandial
• Low blood sugar
• Diabetes millitus is a insulin shock
• Some endocrine tumors make too much insulin or insulin like factors
• s/s you often see a flight or flight response, sympathetic

Question 40

Hepatic Failure

Answer 40

• Causes
  1) Cirrhosis
  2) Hepatitis
  3) Cancer
  4) Hemachromatosis
• Signs and Symptoms
  1) Hepatic encephalopathy – buildup of toxins (NH3) that effect brain function
  2) Changes in NS function  ALOC, reflexes, behavior
• Testing
  1) Blood NH3 test
  2) Liver biopsy
• Understand pathophysiology of hepatic failure
• The liver gets first dibs on the blood coming from
• All the food that you eat the nutrients are absorbed from the small intestine
• Bllod first goes from the hepatic portal vein to the liver
• What ever goes into guts goes to the liver to detoxify it
• If a person takes drugs the liver is going to have first pass metabolism
• If you want to avoid first pass metabolism: iv, PR rectal, under tongue
• Also have other organs that spleen, splenic vein, stomach (gastric veins), pancreas
• Problems with hepatic failure: hepatic veins are compromised
• The blood that is trying to drain from the spleen into the liver? It can’t same with other veins that drain into liver
• Hydrostatic pressure goes up and fluid gets pushed out in interstitial space and looks like ascities
• Spleen can get enlarged, stomach can get compromised
• The esophagus veins also drain towards liver, if this veins can’t drain they get bigger