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Health Assessment ORAL first half > Nervous and Musculoskeletal Systems > Flashcards

Nervous and Musculoskeletal Systems Flashcards

1
Q

What can we do to protect musculoskeletal system with anesthesia?

A
  • With sedation, regional or general anesthesia, we take away the normal protective pain reflexes
  • Determine preop range of motion abnormalities and joint integritu (document baseline)
  • maintain natural range of motion for all anesthetic procedures and sx positioning (document)
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2
Q

What is thoracic outlet syndrome?

A
  • Compression of brachial plexus and SCL vessels near the first rib
    • be certain patient can work or sleep with arms elevated over their head before putting arms beside hear (prone positioning)
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3
Q

How do you perform musculoskeletal assessment for the hip?

A
  • Concentrate on ROM that can impact positioning
  • flexion- supine, pt bends each knee to chest/abdomen
  • abduction- supine pt, stabilize anterior superior iliac spine and abduct the extended leg until the iliac spine moves= limit
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4
Q

What are some consideraitons when patient is on steroids?

A
  • Suppression or disease of pituitary-adrenal axis will prevent the patient from responding to the stress of sx appropriately
  • any patient who has received corticosteroid therapy (suppression of pituitary-adrenal aix) for at least a month in the past 6-12 months needs supplementation
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5
Q

What are some considerations when patient on MAOI?

7 MAO-Is

A

Patients maybe on MAO-Is for depression or parkinson’s (MAO-I type B)

  • Inhibits degradation of monoamines, increasing the serotonin and norepi available at presynaptic nerve terminal for uptake and storage
  • life-threatneing interactions can occur with consumption of foods containtin tyramine and with Ephedrine and Meperidine

MAO-Is: 7

  1. iproniazid
  2. phenelzine
  3. isocarboxazid
  4. moclobemide
  5. befloxatone
  6. brofaromine
  7. selegiline
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6
Q

What are the MAOIs we need to know?

8

A
  1. Befloxatone
  2. Brofaraomine
  3. Iproniazid
  4. Isocarboxazide
  5. Moclobemide
  6. Phenelzine
  7. Selegiline
  8. Tranylcypromine
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7
Q

What are some considerations with methotrexate and anesthesia?

used

SE -5

tests

A
  • Used in MS, ankylosing spondylitis and rheumatoid arthritis
  1. immuno-suppression,
  2. anemia,
  3. thrombocytopenia,
  4. pulmonary toxicity,
  5. renal and hepatic toxicity
  • CBC
  • Chem panel
  • consider PFT, and LFT if hisotry warrants
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8
Q

What are some quesitons to ask for patient with multipel sclerosis?

A
  • Any recent history of illness or infection?
    • Take extra care with infection prevention
  • Which medications are they taking and how often?
  • Steroids in past year?
  • Remission and exacerbation intervals
  • Severity and nature of symptoms
    • respiratory status
    • previous triggers

If on interferon B, will have to stop taking NSAIDs for 48 hours prior to surgery

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9
Q

Anesthetic considerations for patient on disease modifying therapy for MS?

A
  • Disease modifying therapy (immunomodulators) all aincrease risk of infection
    • interferon B (flu like symptoms, hepatotoxicity, myelosuppression, depression)
    • dimethyl fumarate (GI disocmfort, infections)
    • Glatiramer acetate (well tolerated)
    • Natalizumab (leukoencephalopathy, hepatotoxicity)
    • Fingolomid (bradycardia, hepatotoxicity)
    • Teriflunomide (neutropenia, hepatotoxicity)

don’t need to memorize drugs, but know what to assess for in general!

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10
Q

What are some considerations for immunosuppressant drugs around mutliple sclerosis?

A
  • Corticosterois (exacerbations)
    • elevated BG levels, DM, Cushings type picture
  • mitoxantrone (severe myelosuppressiona nd cardiac toxicity- reduced EF- heart failure)
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11
Q

What are some symptom management treatments in MS?

A
  • Bladder dysfucntion (alpha antagonist, anticholinergics VS bethanechol- agonist)
  • Fatigue and depression
  • cognitive dysfucntion (cholinesterase inhibitos, memantine)
  • neuropathic pain
  • spasticity (baclofen)
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12
Q

What is it important to document with MS?

6

A

document pre-eixsting deficits!

  1. paralysis (assess for motor strength)
  2. sensory distubances (assess along dermatomes)
  3. autonimc distrubance (resting HR, orthostatic hypotension)
  4. visual impairment (cranial nerve check)
  5. seizures (meds)
  6. emotional disturbances

Counsel pt regarding increased relapse incidence with surgery

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13
Q

What is important to dcoument with GBS?

illness

symptoms - 6

A
  • Document time course of the disease
    • precipitating factors
    • onset of symptoms
    • disease progression (worsening, stable, improving)
    • should never, ever do elective procedures with GBS
  • Document severity and current states of symptoms
    1. facial paralysis- bulbar involvemet
    2. difficult swallowing- pharyngeal muscle weakness
    3. impaired ventialtion- current ventilatory support required (vent)
    4. decreased DTR- lower motor neurons
    5. extremity paresthesia
    6. pain- HA, backache, muscle tenderness + note meds helpful for contorlling pain
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14
Q

What is important to note with parkinson’s diases?

A
  • Age of dx,
  • recent exacerbation and
  • recent hospitalizations
  • Current and past symptoms
    • (oculogyric crisis- loosing contorl eye movement, staring striaght ahead. How long did it last? What helped?)
    • ANS symptoms (orhtostatic BPs)
    • hx of pergolide therapy - aortic/mitral regurg
    • Temp regulation issues?
    • Pulmonary status optimized
      • dysphagia and/or dyspnea
      • pulmonary infection
  • Continue current meds and note s/e
    • levodopa- what happens if patient misses a dose?
      • need dose every 6 hours
    • anticohlinergics and MAOIs
  • Note natural range of motion for positioning
  • deactivate deep brain stimulators before electrocautery
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15
Q

Considerations for intervertebral disc herniation?

A
  • Natural ROM for positioning and laryngoscopy
  • baseline motor strength and sensation in applicable areas
  • med regimen (pt on high dose opioids), what drug improve pain, what has been ineffective
  • consider potential for operative blood loss
    • CBC
    • Type and cross
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16
Q

Consideration for ankylosing spondylitis?

A
  • Evaluate coexist vasculitis, aortitis, aoritc insuff., pulmonary fibrosis
  • evaluate for severity of kyphosis
  • spo2, ekg, echo, cxr, pft
  • CBC, BUN, Cr
  • D/c nsaids at least 2 days preo
  • may have positioning challenges
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17
Q

Considerations for acute SCI?

A
  • Fluid and blood status
    • CBC, T&C, chem7
  • EKG/CXR
  • Vasopressor requirement?
  • Vent support?
  • Associated injuries

level of lesion?

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18
Q

Consideration for chronic SCI?

A
  • Hx of autnomic dysreflexia? What intitiated it?
  • Old OR/ICU records helpful- response to vasopressors/tracheal sxn
  • Ventilatory reserve - level of lesion
  • assessment of skin integrity
  • positioning- note normal ROM
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19
Q

What are some considations for CVA?

A
  • Hx of recent TIA or CVA increse risk of perioperative stroke
  • optimal time for subsequent elective sx after stroke is controversial
  • ensure optimization has occurred
    • emboli- PFO corrected?
    • a fib 1-3 months antiocoag therapy
    • carotid bruit noted on exam?
      • ask about TIA symptoms (be aggressive with quesitoning!)
      • consider carotid doppler US study- refer vasular sx
20
Q

What are some considerations with CVA, head injury or intracranial tumor?

A
  • Mechanism of injury/ilness
  • location, size, time course of lesion
  • CT/MRI (secondary edema, hydrocephalus?)
  • LOC
  • ICP status
    • current sypmotsm of headache, nausea, vomiting, bardycardia, HTN
  • Eval CV status
  • consider cranial nerve assessment
  • consider muscle strenght and sensation assessment
  • Review meds
    • endocrine status - ? Pituituary tumor
    • fluid
    • cbc
    • t&c
    • electolyte
    • ekg
    • echo
  • Review current vent status
  • note baseline VS and set BP parameter
  • continue current meds
21
Q

Consideration for seizure d/o?

A
  • Type of sz acitivity; typical length, freq, severity, recovery
  • Precipitatin./causative factors (ETOH withdrawal, brain tumor)
  • Hx of status epilepticus (how long did it last, how was it treated, were treatments effective)
  • pharm therapy
    • testing directed based on meds- CBC, plt, electolye panel
    • routine level of anticonvulsants unecessary in pt with good sz contorl
    • cancel elective sx utnil sz d/o optimized by neurologist
22
Q

WHat are things to note for physical exam/lab and tests of patient with Lupus?

10

A

Note natural ROM (arthritis)

  1. note neuromuscular strength, cranial and peripheral neuropathies
  2. note mentation (CNS involvement)
  3. fluid and electolyte status- CMP
  4. Hematologic- CBC, PT/PTT and INR
  5. Skin- note existing rashes
  6. Distal extremities- raynaud’s common- pulse ox may be difficult
  7. Renal fxn- glomerulonephritis, protienuria, albumin level, chem panel
  8. Cardiac status- echo, cardiac consult, pericarditis? conduciton abnormaliities? chf? valuvlar dysfunction?
  9. Pulmonary status- PFT
  10. GI- prone to n/v?
23
Q

What are some medications considerations with lupus?

A
  • Note dose amt, frequency, timing of last dose, side effects
  • drugs that affect coag status
    • ibuprofen
    • indomethain
    • ASA
    • cox-2 inhbitos
    • DVT preventative therpy
  • Immunosuppressive therapy
  • steroids
  • optimized by PCP or rheumatologies
24
Q

Considerations for RA?

A
  • Focus area- airway, neuro, pulm, CV
  • Note natural ROM
    • TMJ- limited mouth opening
    • Atlantoaxial joint- lateral neck radiogrpah or MRI- SUBLAXAATION of atlano-occipital joint
    • Cricoarythenoid arthritis- hoarseness, pain on swallowing, dypnea, stridor, laryngeal tenderness
    • individualized airway plan based on findings
  • Dyspnea is often sign of cardiac ischemia in this patient pop
    • PFT and ABG if you suspect lung involvement (restrictive pattern)
    • EHCO, EKG esp if cardiac involvement suspected
  • consider effect of meds: ASA, NSAIDS, methotrexate, immunosuppressive drug and steroids
25
Q

Considerations in OsteoArthritis?

A
  • Note natural ROM- focus on key problem areas
  • meds for pain relief, what works, what does not work, last dose, etc
26
Q

Consideration with myasthenia gravis?

A
  • Note degree of skeletal muscle weakness, progerssion of the disease
  • note med hx-
    • cholinesterase inhibitors
    • steroids
    • immunosuppressive therapy
  • may stay intubated afterwards, make sure they’re aware
27
Q

Consideraitons for muscular dystrophy?

6

A
  1. Note progression of dx, natural ROM, strenght
  2. Delayed gastric motility RSI, aspiration risk
  3. vent status (PFT, cough strenght) aspiration risk
  4. Cardiac (EKG, echo)
  5. succinycholine contraindicated
  6. may not be extubated right away
28
Q

Considerations for myasthenic syndrome?

A
  • Note degree of skeletal muscle weakenss and progression of disease, meds
29
Q

Marfan syndrome consideration?

A
  1. Cardiopulmonary assessment,
  2. echo,
  3. TMJ,
  4. high pneumothorax risk
30
Q

Questions to ask neuro patients

9

A
  1. Have you ever had a seizure, stroke, or paralysis?
    • Precipitating factors
    • how long did it last
    • how was it treated, medications?
  2. Have you ever been diagnosed as having a tremor or Parkinson’s disease?
    • Where is the tremor ?
    • How long does it last?
    • How is it treated?
    • Any limitations on ADLs?
  3. Have you ever had numbness, tingling, pins-and-needles feelings in your arm or leg that has lasted more than 2 hours?
    • precipitating factors?
    • How long did it last?
    • How was it treated?
  4. Have you ever had a nerve injury? Multiple Sclerosis? Or anyother nervous system disease?
    • precipitating factors
    • causation?
    • When was it diagnosed?
    • Specific symptoms?
    • How is it treated?
    • How often do residual symptoms occurs?
  5. Have you ever had migraine headaches?
    • precipitating factors?
    • How long does it last?
    • How is it treated?
    • How often? Residual symptoms?
  6. Have you take anti-deperssants, sedatives, tranquilizing, anti-seizure mediacations or herbal medications in the last year?
    • What medications where taken and when ?
    • How often?
    • Last dose?
    • What happens if medications are discontinued suddenly?
  7. Have you ever had any pains in your joints or low back pain?
    • Which joints are affected?
    • What are the precipitating factors?
    • Normal range of motion?
    • What makes the pain worse?
  8. Have you been working at your usual job or doing normal activties in the last week, month, year?
  9. Have you taken pain pills or had pain shots in the last 6 months?
31
Q

General Principle of anethesia but important in neuro:

A

With the induction of anesthesia, regional or general, we take away the normal protective pain reflexes

  • focus on determining range of motion abnormalities and joint integrity
  • document baseline
  • maintain natural range of motion for all anesthetic procedures and surgical positioning
32
Q

Assessing the TMJ joint

A

place tips of index finger in front of tragus of ear, ask patient to open mouth, fingertips should drop into the joint spaces as mouth opens.

Check for smooth range of motion, swelling, tenderness.

Snapping and clicking is normal.

ask patient to open and close mouth, protrude and retract jaw

33
Q

Assessing the cervical spine

4

A
  1. Flexion - touch chin to chest
  2. Extension look up at the ceiling
  3. Rotation - turn head to each side, looking directly over the shoulder
  4. Lateral bending - tilt head so touching ear to shoulder
34
Q

Assessing the shoulder girdle

A
  1. Adbuct the arms to the shoulder level
  2. Raise arms vertical position above head, palms facing each other
  3. Place both hands behind the neck with the elbows out to the side
  4. Place both hands behind the small of the back
35
Q

How to assess for thoracic outlet sydrome:

A

Thoracic outlet syndrome = compression of brachial plexus and subclavian vessels near the first rib

Ask pt if they can work or sleep with arms elevated over the head before putting arms beside head in prone position

36
Q

How to assess elbow

A

Flexion and extension: Ask pt to bend and straigthen elbow

Supation and pronation: With arm at sides and elbows flexed, instruct pt to turn palms up (supination) and palms down (pronation)

37
Q

How to assess the hip

3

A
  1. concentarate on ROM that can impact positioning
  2. FLEXION: pt laying supine, tryand bend each knee to chest/abdomen
  3. ABDUCTION: pt laying supine, stabilize anterior iliac spine and and abduct the extended leg until the iliac spine moves - limit
38
Q

Nervous System Assessment should focus on

6

A
  1. Mental Status
  2. Speech
  3. Cranial Nerves
  4. Gait
  5. Motor Function
  6. Sensory Function
39
Q

Cranial Nerve Assessment:

A
  1. Olfactory:
    • Smell test, coffee beans, ETOH pad
  2. Optic:
    • Confrontation test, pupillary reaction to light
  3. Occulomotor,
    • Pupillary reaction to light
    • Occulomotor movements, specifically up and down
  4. Trochlear - superior oblique muscle
    • Extraoccular movements, specificially diagonal motions
  5. Trigeminal
    • Ask pt to clench his or her teeth, palpate temporal and masseter muscles for normal muscle tones in jaw and temporal regions
    • check sensation in forehead, cheak, and chin (mental region)
    • Also could do cotton ball to assess for corneal reflex
  6. Abducens
    • Extraoccular movement, side to side (lateral rectus)
  7. Facial
    • Ask patient to raise eyebrows, frown, close eyes tightly as you try and open them. Show teeth, smile, puff out both cheeks
  8. Acoustic
    • Hearing - usually formally assessed by audiology
  9. Glossopharyngeal tested with VAGUS
  10. Vagus
    • 9 + 10 ,Voice hoarseness, gag reflex, “Ahhhh” palate should rise symmetrically
  11. Spinal Accessory
    • Ask pt to turn head to each side against your hand
    • Ask pt to shrug upwards against you pushing down on your shoulders
  12. Hypoglossopharyngeal
    • Tongue movement, ask them to move tongue side to side
40
Q

Dermatomes of hands and notable landmarks

5

A
  1. Thumb = C6 (sex)
  2. middle finger = C7
  3. pinky finger = C8 (ate a booger)
  4. nipple line = T4
  5. Umbilicus = T10
41
Q

Muscle Strength is graded on

A

Muscle Strength is graded on a 0-5 scale

test flexion and exntension and compare symmetry

  1. No muscular contraction detected - flaccid
  2. Barely detectable contraction
  3. Active momvement with gravity eliminated
  4. Active movement against gravity
  5. Active movement against gravity with some resistance
  6. Active movement against gravity with full resistance
42
Q

NERVES RESPONSBILE FOR:

  1. Elbow Flexion
  2. Elbow Extension
  3. Grip
  4. Finger abduction
  5. Opposition of the thumb
A

NERVES RESPONSBILE FOR:

  1. Elbow Flexion = C5, C6
  2. Elbow Extension = C5, C6, C8
  3. Grip = C7, C8, T1,
  4. Finger abduction = C8, T1, ulnar nerve
  5. Opposition of the thumb = C8, T1, median nerve
43
Q

Nerves Responsible for

  1. Hip Flexion + ADduction:
  2. Hip ABduction:
  3. Hip Extension:
A

Nerves Responsible for

  1. Hip Flexion + ADduction: L2, L3, L4
  2. Hip ABduction: L4, L5, S1
  3. Hip Extension: S1
44
Q

Nerves Responsible for

  • Knee Extension:
  • Knee Flexion:
  • Dorsiflexion:
  • Plantar Flexion:
A

Nerves Responsible for

  • Knee Extension: L2, L3, L4
  • Knee Flexion: L4, L5, S1, S2
  • Dorsiflexion: L4, L5
  • Plantar Flexion: S1
45
Q

Glasgow Coma Scale

A

Defines neurological function impairment

Eyes open - 1-4

  • Open spontanously: 4
  • Never open: 1

Best Verbal Reponse 1-5

  • None: 1
  • Oriented: 5

Best Motor Response:

  • None: 1
  • Follows commands: 6

mortality closely related to intital score

if someone presents with intial GCS <8 50% will recover

Scores of 8 or less are considered severe (coma) - will require intubation and controlled ventilation for ICP and airway conrol

46
Q
A

Health Assessment ORAL first half (7 decks)

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