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Advanced Clinical Assessment > Neuro > Flashcards

Neuro Flashcards

1
Q

Subjective

  • _ _, D______
  • S____ or loss of ________
  • S_____
  • Changes in v______
  • Changes in h______
  • Changes in s______
  • N______ or Pa_____
  • Pa______ or We______
  • Changes in m____
  • Changes in sl_____
  • A_____, D___ use
A
  • HA, Dizziness
  • Syncope, Consciousness
  • Seizure
  • vision
  • hearing
  • speech
  • Numbness, Parasthesia
  • Paralysis, Weakness
  • mood
  • sleep
  • Alcohol, drug use
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2
Q

Health Promotion and Counseling

  1. Preventing _____ or _ _ _
  2. Reducing risk of peripheral ________ (could be connected to __, m_______, are symptoms getting _____? Such as difficulty _____ shirt or w____?) ​
  3. Detecting the “three D’s” (3)
A
  1. Stroke, TIA
  2. Neuropathy (DM, medications, worse, buttoning, walking)
  3. Delirium, Dementia, Depression
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3
Q

Key Principles

As you examine the patient, remember 3 important questions:

  1. Is _____ status intact?
  2. Are ____ and _____ sided findings the ____, or symmetric?
  3. If findings are asymmetric or otherwise abnormal, do the causitive lesions lie in the _____ or _____?
A
  1. mental
  2. right, left, same
  3. CNS or Peripheral nervous system
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4
Q

Organize your exam into categories

  • _____ status
  • S_____ and La______
  • _____ nerves
    • M____ system
    • S____ system
  • Re______
  • C______
  • G_____
A
  • Mental
  • Speech, Language
  • Cranial
    • Motor
    • Sensory
  • Reflexes
  • Coordination
  • Gait
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5
Q

Mental Status

  • O_____
  • Level C_______
  • J_______
  • M____
  • T_____ process
  • I_____
  • A_____
A
  • Orientation
  • Consciousness
  • Judgement
  • Mood
  • Thought
  • Insight
  • Affect
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6
Q

Mental Status Chart

  1. Alertness​​
    • Speak to the patient in a _____ tone of voice. An alert patient opens the ____, ___ at you, and responds fully and ________ to stimulate (arousal intact)
  2. Lethargy
    • ​​Speak to the patient in a ____ voice. For example, call the patient’s ____ or ask “How are you?”
    • A lethargic patient appears d____ but ____ the eyes and looks at you, responds to questions, and then falls _____.
  3. Obtundation
    • ​​_____ the pt gently as if awakening a sleeper
    • An obtunded patient opens eyes and looks at you, but responds _____ and is somewhat c_____. Alertness and interest in ______ is ______.
  4. Stupor
    • ​​Apply a ______ stimulus. For example, p____ a tendon, ___ the sternum, or roll a ____ across a ___ bed. (No stronger stimuli _____!)
    • A stuporous pt arouses from sleep only after ____ stimuli. Verbal responses are ____ or even _____. The pt lapses into an _____ state when the stimulus ceases. There is ______ awareness of self or the environment.
  5. Coma
    • ​​Apply repeated _____ stimuli
    • A comatose pt remains ______ with eyes _____. There is no evident response to inner n____ or e____ stimuli.
A
  1. Alertness
    • ​​normal, eyes, looks, appropriately
  2. Lethargy
    • ​​loud, name
    • drowsy, opens, asleep
  3. Obtundation
    • ​​Shake
    • slowly, confused, environment, decreased
  4. Stupor
    • ​​painful, pinch, rub, pencil, nail, needed
    • painful, slow, absent, unresponsive, minimal
  5. Coma
    • ​​painful
    • unarousable, closed, need, external
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7
Q

Common Causes of AMS

AEIOUTIPS

A
  • Alcohol
  • Epilepsy
  • Insulin
  • Overdose
  • Uremia (maybe in advanced or septic pt)
  • Trauma (could be trauma that causes a lot of blood)
  • Infection (sepsis)
  • Psychological/Poisoning
  • Stroke/Shock
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8
Q

The logical, coherent, and relevance of a patient’s thoughts, ____ people think.

  • Speech characterized by indirection and delay due to the patient’s excessive use of details that have no connection to the point =
  • Speech where a person shifts topics with no apparent relation between the topics =
  • Accelerated change of topics in a very fast but generally coherent manner =
  • Speech that is comprehensible because it is illogical =
  • Fabrication of facts to hide memory impairment =
A

Thought Processes

HOW people think

  • Circumstantiality (kind of talks in circles, asking about a HA and they start talking about their fingernails)
  • Derailment (A to B to C to D topics but they are making sense)
  • Flight of ideas
  • Incoherence (they aren’t making sense “theres a bird in my head”
  • Confabulation (to avoid embarassment)
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9
Q

The observable mood of a perosn expressed through their facial expression, body movements, and voice =

  • Assess the patient’s facial _______
    • Lack of facial movement - can be seen due to ta physical reason such as Parkinson’s disease or psychological reason such as profound depression =
  • Assess the patient’s m____, affect and relationship to p_____ and th_____
    • Does the affect reflect the m_____
    • Is the affect s____ or l_____ (mood changing from happy to tears and back quickly)
    • Does the patient seem to ___ or ___ things you don’t
A

Affect

  • expression
    • flat affect
  • manner, person, things
    • mood
    • stable, labile
    • see, hear
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10
Q

Process of comparing and evaluating different possible courses of action =

  • Ask about the _____ behing their clinical or hospital visit; patients with psychological disorders ____ insight into their _____
  • You can usually assess _____ by noting the pts responses to s_____ on their relationships, jobs, finances
A

Judgment

  • reasons, lack, disease
  • judgment, stressors
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11
Q

Glasgow Coma Scale

  • What is it used for?*
  • Do you want to score higher or lower?*

What are the 3 components of the scale?

A
  • To assess brain trauma*
  • HIGHER*

Best eye-opening response

Best motor response

Best verbal response

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12
Q

Delirium

  • _____ onset (ie urosepsis)
  • F_______ course
  • Lasts ____ to ____
  • _____ disrupted
  • Associated with i_____ or d____ toxicity
  • Distubred level of c________
  • A____ or S_____ (can have both)
  • Disorganized th____ process
  • Disoriented mostly to t_____
A
  • Acute
  • Fluctuating
  • hours to weeks
  • Sleep
  • illness, drug
  • consciousness
  • Agitated, Somnolent
  • thought
  • time
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13
Q

Dementia

  • _____ onset
  • S_____ progressing course
  • Lasts ____ to _____
  • Sleep f______
  • ___ usually associated with illness or drugs except with Alzheimers
  • ___ change in consciousness until ____ in disease
  • Normal to slow b_____
  • Difficulty finding w_____
  • Often flat or d_______ mood
A
  • Insidious
  • Slowly
  • months, years
  • fragmented
  • Not
  • No, late
  • behavior
  • words
  • depressed
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14
Q

Altered Mood

  • Depression
    • More common with significant medical c______
    • Concern for a_____, d___ use
    • Can be related to m_______
      • ____ blockers
      • S_____
      • B________
      • _______ drugs - Sinemet
      • Anti_______
  • PHQ-2
    • What are the two questions?
A
  • Depression
    • conditions
    • alcohol, drug
    • medication
      • Beta
      • Steroids
      • Benzodiazepines
      • Parkinson’s
      • Anticonvulsants
  • PHQ2
    • Have you been feeling down, depressed, or hopeless (depressed mood)?
    • Have you felt little interest or pleasure in doing things (anhedonia)?
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15
Q

Assessing Speech

  1. _______ of speech: is the pt silent? Must you drag ever word out of the pt? Does the patient speak excessively?
  2. R____: is the speech fast (pressured such as in a manic episode) or slow (such as in depression)?
  3. L____: Does the pt speak loudly (like in mania) or softly (social anxiety or depression)
  4. A________: Does the pt speak clearly?
  5. F_______: This involves the rate, flow, and melody of speech.
    • ​​Hesitancies in speech (as seen in pts with aphasia from _____)
    • _______ inflections (schizophrenia or severe depression)
    • __________: in which words or phrases are substituted fro the word a person can’t remember (ex) “the thing you block our your writing with” for an “eraser”​
    • _______: words are malformed “I write with a den”, wrong “I write with a branch”, or invented “I write with a dar”
A
  1. Quantity of speech Think about in terms of diff pts, not necessarily neurological if silent, could be in abusive situation
  2. Rate
  3. Loud
  4. Articulation
  5. Fluency
    • ​​strokes
    • Monotone
    • Circumlocutions
    • Paraphasia
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16
Q

Disorders of Speech

(2)

A

Dysarthria

Dysphonia

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17
Q

Difficulty in articulating words with impaired movement of the palate, tongue, or lips =

  • Usually a consequence of?
  • Inability to understand or speak language =
    • ​2 types
A

Dysarthria

  • CNS lesions (brain tumor, ALS)
  • Aphasia
    • ​Receptive
    • Expressive
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18
Q

Difficulty speaking because of impaired function ​

Secondary to impaired function of the?

A

Dysphonia

vocal cords

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19
Q

Aphasia

(2)

A

Wernicke’s Aphasia

Broca’s Aphasia

Although is it important to recognize aphasia early in your encounter with a patient, integrate this info with your neuro exam as you approach a diagnosis

You want to try and recognize aphasia earliest in encounter as possible

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20
Q

Wernicke’s Aphasia

  1. Qualities of Spontaneous Speech:
  2. Word Comprehension:
  3. Repetition:
  4. Naming:
  5. Reading Comprehension
  6. Writing:
  7. Location of Lesion:
A
  1. Fluent, often rapid, voluble, and effortless. Inflection and articulation are good, but sentences lack meaning and words are malformed (paraphasia) or invented (neologisms). Speech may be totally incomprehensible
  2. Impaired
  3. Impaired
  4. Impaired
  5. Impaired
  6. Impaired
  7. Posterior superior temporal lobe
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21
Q

Broca’s Aphasia

  1. Qualities of Spontaneous Speech
  2. Word Comprehension
  3. Repetition
  4. Naming
  5. Reading Comprehension
  6. Writing
  7. Location of Lesion
A
  1. Nonfluent; slow with few words and laborious effort. Inflection and are impaired but words are meaningful with nouns, transitive verbs, and important adjectives. Small grammatical words are often dropped
  2. Fair to good
  3. Impaired
  4. Impaired, though the patient recognizes objects
  5. Fair to good
  6. Impaired
  7. Posterior inferior frontal lobe
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22
Q

Motor System-Examination

  • Position, movement, muscle bulk, and tone
    • Observe body ______ and ______ movements such as t____, t___, fa_______
    • Inspect muscle _____; note any at______ (from hospitalization or cast)?
    • Assess muscle ____ - flex and extend arm and lower leg for residual tension -> slight ______ to passive stretch is ______
A
  • Position, movement, bulk, tone
    • ​position, involuntary, tremors, tics, fasciculations
    • bulk, atrophy
    • tone, resistance, normal
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23
Q

Pictures on how to test Motor System of Upper Extremities

Do not let me push ___, pull your w____, push providers hand ____

A

down, wrist, down

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24
Q

Pictures on how to exam Lower Extremities Motor System

A
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25
Q

Muscle Strength Grading

  • What grade is the following? (0-5 scale)
    1. Active movement against gravity
    2. Active movement against full resistance without evident fatigue; this is normal muscle strength
    3. No muscular contraction detected
    4. Active movement of the body part with gravity eliminated
    5. Active movement against gravity and some resistance
    6. A barely detectable flicker or trace of contraction
  • Ask the pt to move actively against your opposing resistance,assignGrade __ if the patient overcomes your opposing movement
  • If the patient can only move against gravity, assign Grade __
A
  • Scale 0-5
    • 3
    • 5
    • 0
    • 2
    • 4
    • 1
  • 5
  • 3
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26
Q

Examination-Muscle Strength

  • Test the following muscle groups and movements
    • ​B_____ and T_____, w____: flexion and extension
    • Hand____, f____: abduction and adduction, ____ opposition
    • T____: flexion, extension, lateral bending
    • H__: flextion, extension, abduction, and adduction
    • K____ and A_____ - flexion, extension
A
  • Muscle groups and movements
    • ​Biceps, Triceps, Wrist
    • Handgrip, finger, thumb
    • Trunk
    • Hip
    • Knee, Ankle
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27
Q

Examination-Coordination

​Test Coordination,including

(4)

A

Rapid Alternating movements

Point to point movements

Gait

Stance (The Romberg Test, Pronator Drift)

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28
Q

Examination Coordination cont.

  1. Rapid alternating movements ​
    • patient ____ hand rapidly over and back on th___
    • taps tip of index _____ on distal th___
    • taps ball of ____ rapidly on your ____
  2. Point to point movements
    • ​​patient touches n___ then your index ____ as you move it to different _______
    • Patient moves h_____ from opposite k____ down the ____ to the big___
  3. Gait
    • ​​walks across _____
    • walks ____ to ____
    • walks _____ then _____
    • ____ in place (keep in mind older/osteoporosis probs cannot)
  4. Stance
    • ​​The Romberg Test
      • ​pt stands with feet _____ and eyes ____, then with eyes _____ for __-___ seconds without support
      • Positive test =
    • Pronator Drift
      • ​Patient _____ for 20-30 seconds with both ___ straight ______, ____ up, eyes ____, tap arms briskly _______
      • Positive test =
A
  1. Rapid alternating movements
    • ​​turns, thighs
    • finger, thumb
    • foot, hand
  2. Point to point movements
    • ​​nose, finger, positions
    • heel, knee, shin, toe
  3. Gait
    • room
    • heel to toe
    • toes then heels
    • Hops
  4. Stance
    • ​​together, eyes open, closed 30-60 s,
    • Loss of balance when eyes closed +
    • ​​stands, arms, forward, palms, closed, downward
    • Pronation or downward drift of arm +
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29
Q

Impaired Muscle Tone

  • ______ = _____ motor neuron of the ______ tract at any point from the cortex to the spinal cord - increased resistance to passive lengthening, then may suddenly give way (clasp-knife phenomenon) - ie muscular dystrophy
  • ________ = basal ______ system - constant state of resistance; resists passive movement in any direction
    • Lead pipe rigidity
    • Cogwheel rigidity
  • _______ = _____ neuron at any point from the anterior horn cell to the peripheral nerves-decreased muscle ____, muscle feels ____, soft and flabby, weak and easily f_____
A
  • Spastic = upper, corticospinal
  • Rigid = ganglia
  • Flaccid = lower, tone, limp, fatigued
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30
Q

Tremors

(3)

A
  1. Resting (or static) tremors
  2. Postural tremors
  3. Intention tremors (becomes obvious and often exaggerated as the need for precise movement increases)
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31
Q

Reflexes

  • Select a properly _____ hammer
  • Encourage the pt to _____; position the limbs properly and symmetrically
  • Hold the hammer _____ between your thumb and index finger so that it swings freely in an ___
  • Strike the tendon with a b____ direct movement; use the ______ force needed to obtain a response
  • Use re_________ when needed
  • ______ the response
A
  • weighted
  • releax
  • loosely, arc
  • brisk, minimum
  • reinforcement so if you think someone had a weak response, assess another tendon then double back
  • Grade
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32
Q

Record Deep Tendon Reflexes

Range is __ - __

  • Average; normal =
  • Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension) =
  • No response =
  • Brisker than average; possibly but not necessarily indicative of disease =
  • Somewhat diminished; low normal =
A

0 - 4+

  • 2+ (normal)
  • 4+ (markedly hyperactive with clonus)
  • 0 (absent)
  • 3+ (hyperactive reflex)
  • 1+ (present but diminished)
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33
Q

Deep tendon reflexes with ___ levels for each response helps localize any _____

  • Biceps reflex = __-__
  • Triceps reflex = __-__
  • Supinator or Brachioradialis = __-__
  • Knee reflex = __-__
  • Ankle reflex = primarily ___
A

cord, abnormalities

  • C5-6
  • C6-7
  • C5-6
  • L2-4
  • S1
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34
Q

Test Arm Reflexes

1) ______ C5-C6
2) _____ C6-C7
3) ______ C5-C6

A

1) Biceps (how to hold limb, don’t squeeze, using thumb to transfer impulse)
2) Triceps
3) Brachioradialis

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35
Q

Leg Reflexes

  1. Patellar __-__
    • can use the ___ of hammer for an adult, for child use the ___
  2. Achilles ___
    • use ___ of hammer for Achilles too
A
  1. L2-L4
    • back, tip
  2. S1
    • back
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36
Q

Cutaneous Reflexes

(3)

A

Abdominal Reflexes

Plantar Response (Babinski)

Anal reflex (wink)

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37
Q

Abdominal Reflex Nerve Segments

  • Upper abdomen __-__
  • Mid abdomen __-__
  • Lower abdomen __-__
A
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38
Q

Plantar Response and Anal Reflex Nerve Segements

  • __-__
  • Positive babinski normal in?
  • __-__
  • So again if you have a lesion in S2-S4 this reflex may __ be present
A
  • L5-S1
  • normal in pediatric patients until a certain age
  • S2-S4
  • not be present
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39
Q

Pathologic Reflexes

  1. Babinski
    • Method of testing: Stroke _____ aspect and ____ ball of foot
    • Abnormal Response (Reflex is present): ______ of great toe, _____ of toes
    • Indications: C________ (pyramidal) tract disease
  2. Oppenheim
    • Method of testing: Stroke a_____ medial t____ muscle
    • Abnormal Response: ____ as babinski
    • Indications: _____ as babinski
  3. Gordon
    • Method of testing: Firmly _____ c____ muscles
    • Abnormal response: ____ as babinski
    • Indications: _____ as babinski
A
  1. Babinski
    • lateral, across
    • Extension, fanning
    • Corticospinal
  2. Oppenheim
    • anterior, tibial
    • same
    • same
  3. Gordon
    • squeeze calf
    • same
    • same
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40
Q

Pathologic Reflexes

  1. Hoffman
    • Method of testing: F_____ distal ph____ of middle or index f_____
    • Abnormal response: C______ of fingers and thumb
    • Indications: ____ as babinski
  2. Kernig
    • Method of testing: Raise leg ____ or f___ thigh on abdomen, then _____ knee
    • Abnormal response: R______ to straightening, ____ down posterior thigh
    • Indications: _______irritation
  3. Brudzinski
    • Method of testing: Flex c___ on c_____, ____ hips and knees
    • Abnormal response: R_____ and ____ in neck, with _____ of hips and knees
    • Indications: _______ irritation
A
  1. Hoffman
    • Flick, phalynx, finger
    • clawing
    • same (corticospinal disease)
  2. Kernig
    • straight, flex, extend
    • Resistance, pain
    • Meningeal
  3. Brudzinski
    • chin, chest, watch
    • resistance, pain, flexion
    • meningeal

Babinski, Brudzinski, and Kernigs are the three most common ones we use to loof for meningeal irritation in meningitis (positive reflex = positive test)

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41
Q

Sensory Examination: General Principles

  • Compare _____ areas on both sides of the body
  • When testing p____, te____, and t____, compare d____ with p____ areas of the extremities
  • M___ out the b_______ of any area of sensory loss or hypersensitivity
A
  • symmetric
  • pain, temp, touch, distal and proximal
  • Map out boundaries
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42
Q

Sensory System Components

  • S______ tract
  • P_____ column
A
  • Spinothalmic tract
  • Posterior column
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43
Q

Spinothalmic Tract

Test pain: ____ and ____

Light touch: c_____ wisp

Temperature: ommitted if pain is ____

  1. C4 = ______
  2. C6T1 = inner outer aspect of _____
  3. C6-C8 = T____ and P_____
  4. L2 = Front of _____
  5. L4-L5 = Medial and lateral aspect of _____
  6. S1 = little ____
A
  • sharp and dull
  • cotton
  • intact
  1. Shoulders
  2. forearm
  3. Thumbs, Pinky
  4. thighs
  5. calves
  6. toe
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44
Q

Posterior Column

  1. Vibration​
    • ​​Using a tuning fork and then place on the distal joint of the _____ and big ___
    • Ask the person to tell you when the vibration ___
    • When ready clasp your hand over the fork to make the vibration stop
    • First sensation to go in p______ n_____
    • If abnormal move p______
  2. Proprioception
    • ​​Grasp the patient’s big ___
    • Holding it by the sides
    • Move the toe __ and ___
    • Asking the person to ______up or down as you move the toe in a small arm
A
  1. Vibration​
    • ​​finger, big toe
    • stops
    • peripheral neuropathy
    • proximally​​​
  2. Proprioception
    • ​​toe
    • sides
    • up and down
    • respond
45
Q

Posterior Column: Tactile Discrimination

  • Stereognosis =
    • ​Distinguish ___ and ___ on a coin
  • Two point discrimination
    • ​Using a paper clip -> point pressure on __ parts of finger pad, should be able to feel ___ at the same time
    • Distance between the 2 stimuli should be <__mm if unable to discriminate
    • Move apart until pt can identify both pressures, ___ the distance in __
  • Extinction
    • ​_____ touch an area on both sides of body
    • Ask where patient feels your touch, should feel ____
    • Stimulus on the side _____ the damaged ____ is e______
  • Graphesthesia: _____ identification
    • ​unable to identify # means =
    • How to test graphesthesia?
A
  • Stereognosis = ability to identify an object by feeling it
    • heads, tails
  • Two point discrimination
    • ​2, both
    • 5mm
    • mark, cm
  • Extinction
    • ​Simultaneously
    • both
    • opposite, cortex, extinguished (so if they can’t feel you on the right side the left side of cortex is damaged)
  • Graphesthesia: number
    • lesion in sensory cortex
    • Draw # on person’s hand and ask them to identfiy it
46
Q

Common Patterns of Sensory Loss

  • Hemi or full loss sensory loss depending on level of spinal cord injury
  • Right cortex damage = left side loss and vice versa*
A
47
Q

Coordination

  • C______
    • Rapid ______ Movement
    • P____ to P____ Movement
      • F____ to N____
      • H____ to Sh___
      • F____ to F____
    • _______; proprioception
    • ______ drift: upper neuron disorder
A
  • Cerebellum
    • Alternating
    • Point to Point
      • Finger, Nose
      • Heel, Shin
      • Finger to Finger
    • Romberg
    • Pronator

“had a drink an hour ago and it goes straight to my cerebellum”

48
Q

Gait

Types of Gait

  • S_____
  • N_____ walking
  • T____ walking
  • H___ to T___
  • S_____ or Foot ___
  • S____ Hemiparesis
  • P_____
  • Cerebellar A____
A
  • Station
  • Normal
  • Tandem
  • Heel to Toe
  • Steppage or Foot Drop
  • Spastic Hemiparesis
  • Parkinsonian
  • Cerebellar Ataxia
49
Q

Ataxic Gait

  • Ataxic gait usually a ____ stance, unsteadiness in ____, tendency to j___/lunge sideways
    • ​A way to test this is to ask pt to walk ____ (pt will have a lot of difficulty)
A
  • wide, trunk, jerk
    • ​tandem -> difficulty
50
Q

Parkinsonian Gait

  • Parkinsonian: ___kinetic, pt will have s____/leaned forward posture, difficulty i____ gait, small sh____ steps, t_____ in hands associated, picking up of s____, pt will turn on b____ (like a statue moving around), again having difficulty initiating gait
A
  • hypokinetic, stooped, initiating, shuffling steps, tremor, speed, block
51
Q

Steppage Gait

  • 2 common patterns with food drop
    • ​Steppage Gait = hiking the __
    • Foot slap gait = ______ foot slap

Scissoring

  • over______ feet while walking (pointed _____)
A
  • 2 patterns w foot drop
    • ​hip
    • audible
  • overlapping (pointed inwards)
52
Q

Headaches

Headache History

  1. A__, T___, and M____ of onset
  2. HA p______ (during period, in afternoon from no caffeine?)
  3. Fr_____, In_____, and Du____ of attack
  4. Presence or absence of a___ or prodrome
  5. Q____, si___, r____ of pain
  6. A_____ sx and abnormalities (nausea, pain)
  7. Prec____ and R____ factors
  8. Effect of pain on a_____
  9. Past Medical ____
  10. F_____ hx of migraine
  11. Me____
  12. R______ to previous treatment
  13. Any recent changes in v_____
  14. Association with recent t____
  15. Any recent changes in sl____, ex____, w___, or d___ (not enough sleep i have a HA)
  16. State of g____ health
  17. Change in w___ or life____
  18. Change in method of ____ control (women)
  19. Relationship to m____ cycle
  20. Possible association with en____ factors (all____)
A
  1. Age, Time, Mode
  2. Pattern
  3. Frequency, Intensity, Duration
  4. aura
  5. Quality, site, radiation
  6. Associated
  7. Precipitating, relieving
  8. activity
  9. Hx
  10. Family
  11. Medication
  12. Response
  13. vision
  14. trauma
  15. sleep, exercise, weight, diet
  16. general
  17. weight, lifestyle
  18. birth
  19. menstrual
  20. environmental (allergies)
53
Q

Differential Diagnoses of Headache

  1. Congenital: ____ Cell, Bleed A_____
  2. Environmental: T_____, Poll__/Poll____, St______
  3. Iatrogenic: L____ puncture, Caffeine w_____, Recent ___ tube, Poor l___ correction, Poor fit of den____
  4. Infections: ____myelitis, Bacterial, Viral M_____, Abscess Enc_____, ____itis, C____ivitis, Ot____
  5. Inflammatory: T____ Arteritis, All____, Ir____, My____
  6. Mechanical: Old or recent f____, Mi____, Cont____, Filled S____, Foreign b____, G____ teeth, Im____
  7. Neoplastic: Pa____, T____, M_____
  8. Psychologic: Vaso____, St____
A
  1. Sickle, Aneurysm
  2. Trauma, Pollen/Pollution, Stresses
  3. Lumbar, withdrawal, NG, lens, dentures
  4. Osteomyelitis, Meningitis, Encephalitis, Sinusitis, Conjunctivitis, Otitis
  5. Temporal, Allergies, Iritis, Myopathy
  6. fracture, migraine, contusion, sinuses, body, grinding, imbalance
  7. Pagets, Tumor, Melanoma
  8. Vasospasm, Stress

Underlying Processes of HA

54
Q

HA: Most Important

  • Always ask about the p_____ of the HAs
  • Do they ____ an individual at night or w____ first thing in the morning
  • Are they worse with increased pressure such as s____, c_____, s____ to stool
  • Are they the worst HA they ____ ___
A
  • progression
  • wake, worse
  • sneezing, coughing, straining
  • ever had
55
Q

Red Flags

SNOOPS

  • ​S
  • N
  • O
  • O
  • P
A
  • Systemic symptoms (fever, weight loss)
  • Neurologic sx such as confusion, impaired alertness, consciousness
  • Onset sudden, aburpt or split second
  • Older, new onset or progressive, pts > 50 (giant cell arteritis)
  • Previous HA history, first HA or new or different HA, change in attack, frequency, severity, or clinical features
56
Q

Types of HAs

  • Primary (4)
  • Secondary =
A
  • Tension
  • Migraine
  • Cluster
  • General
  • Caused by underlying structural, systemic or infectious process (infection, bleed, tumor, medication)
57
Q

Differentiating Primary HA

Which HA does this describe?

  • Unilateral in 60-70%; bifrontal or global in 30%
  • Gradual, crescendo pattern, moderate or severe intensity; aggravated by routine physical activity
  • Pt prefers to rest in dark, quiet room
  • 4-72 hrs
  • Asctd sx: N/V, photophobia, may have aura (usually visual, but can involve other senses or cause speech or motor deficits)
A

Migraine Headaches

58
Q

What HA does this describe?

  • Bilateral
  • Pressure or tightness which waxes and wanes
  • Patient may remain active or may need to rest
  • Variable
  • No asctd. sx
A

Tension HA

59
Q

What HA does this describe?

  • Always unilateral, usually begins around eye or temple
  • Pain begins quickly, reaches a crescendo within minutes; pain is deep, continuous, excrutiating, and explosive in quality
  • Patient remaines active
  • 30min-3hrs
  • Ipsilateral lacrimation and redness of eye, stuffy nose; rhinorrhea; pallor; sweating; Horner’s syndrome; focal neurologic symptoms rare; sensitivity to alcohol
A

Cluster Headache

60
Q

Migraines

SULTANS

  1. 1st Criteria (need __ from this list)
    • S
    • U__L____
    • T____
    • A____
  2. 2nd Criteria (need __ from this list)
    • N
    • S
A
  1. 2
    • Severe
    • UniLateral
    • Throbbing
    • Activity worsens HA
  2. 1
    • Nausea
    • Sensitivity to light/sound
61
Q

Headaches associated with Illness

(2)

A

Sinusitis

Meningitis

62
Q

Sinusitis

  • Cause is m____ in____ due to _____
  • Located ____ eye or cheek, __lateral or __lateral
  • A____ or th_____
  • Onset is ____ lasts several ___ at a time; recurs over d___
  • Local t______, nasal c______, discharge and f_____
  • ______ by coughing, sneezing, and jarring the head
  • More common in ppl with?
A
  • mucusal inflammation, bacterial
  • above, uni or BL
  • Aching, throbbing
  • variable, hours, days
  • tenderness, congestion, fever
  • Aggravated
  • allergic rhinitis
63
Q

Meningitis

  • What is it?
  • ______ location, s___ throbbing, _____ in quality
  • Fairly ____ onset, lasting ____
  • Associated with (2)
  • Causative agent in adults (2)
  • _____ in adolescents prior to college (bc easily spread in campus dorms dt close quarters)
A
  • Infection of the meninges
  • Generalized, steady, severe
  • rapid, days
  • fever >38, nuchal rigidity
  • S. pneumonia, Neisseria meningitides
  • Vaccination
64
Q

Headaches in Older Adults

(2)

A

Temporal Arteritis

Trigeminal Neuralgia

65
Q

Temporal Arteritis

  • Chronic ______ of the? Often associated with ______
  • Localized near the involved _____ (temporal or occipital); may become g______
  • Aching, throbbing, bu____ oftn severe (usually burning)
  • Onset is gradual or rapid
  • ____ duration
  • Recurrent or persistent over w____ to m____
  • Tenderness of the a____ scalp, fever, malaise, fatigue and anorexia; m_____aches and stiffness, v____ loss or blindness
A
  • inflammation, cranial arteries, polymyalgia
  • artery, generalized
  • burning
  • Gradual or rapid
  • variale
  • weeks to months
  • adjacent, muscular aches, visual loss or blindness
66
Q

Trigeminal Neuralgia

  • Mechanism ______
  • Location in ch___, j___, l___, or g___
  • Sharp, brief, lightning like ____, very _____
  • Onset is ____
  • Each jab is t____
  • Pain may be t______ for months then disappears, the recurs; uncommon at night
  • E______ results from ___ (really detrimental to QOL)
  • Typically ______ by touching certain areas of the lower face or by chewing, talking, brushing, teeth
  • Consider in older adults
A
  • variable
  • cheeks, jaw, lips, gums
  • jabs, severe
  • abtupt
  • transient
  • troublesome
  • Exhaustion from pain
  • triggered
67
Q

HA That can occur from Trauma

(2)

A

Mild traumatic brain injury (mTBI) Concussion

Chronic Subdural Hematoma

68
Q

Mild traumatic brain injury (mTBI) Concussion

  • Headache can present when?
  • Related to cellular m____ cas____ that occurs right after an injury coupled with diminished _____ supply
  • Headache _____ with increased mental or physical exertion (sports, reading, watching tv exacerbates trauma to the brain)
  • Usually resolves within __-__ days in adults but can last months to years
  • Associated with ______ impairment
A
  • immediately, hours, days, or weeks later
  • metabolic cascade, energy
  • intensifies
  • 10-14 days
  • cognitive
69
Q

Chronic Subdural Hematoma

  • Caused by _____ into the ______ space after t____
  • Variabe in l_____
  • S____, Ac____
  • ____ onset weeks to months after injury or Progressively severe but may be obscured by ______ consciousness
  • Associated with changes in p_____, hemi_____
  • Injury is often ______
A
  • bleeding, subdural, trauma
  • location
  • Steady, aching
  • Gradual, clouded
  • personality, hemiparesis
  • forgotten
70
Q

Space Occupying Headache

  • Caused by dis______ of or traction on pain sensitive ____ and ____ or p______ on n____ in the skull
  • Pain location depends on location of _____
  • Aching, steady, v____ in intensity
  • V____ onset
  • Often ____ duration, i_____ but pro_____
  • N___logical and mental sx and __/__ may develop
  • ______ by coughing, sneeaing or sudden movements of the head
A
  • displacement, arteries, veins, pressure, nerves
  • tumor
  • variable
  • variable
  • brief, intermittent, progressive
  • Neurological, N/V
  • Aggravated
71
Q

Syncope

  • Ask what the pt was _____ prior to the episode
  • Was the person s____, s____, or l_____ down (pt quickly stood and became syncopal could be orthostatic hypotension)
  • Was there any _____ signs
  • D_____ of the episode
  • Could _____ be heard
  • Was o____ and o____ of the episode fast or slow
  • Were there any p______ prior to the episode
  • Is there a hx of ____ disease
  • Was the episode ____ by anyone?
A
  • doing
  • sitting, standing, lying
  • warning
  • duration
  • voices
  • onset, offset
  • palpitations
  • heart
  • observed
72
Q

Types of Syncope

  1. C______
  2. Hy_____
  3. Pulmonary ______
  4. A_____
  5. ____glycemia
  6. T _ _
  7. A_____
A
  1. Circulatory
  2. Hypoxia
  3. Emboli
  4. Anemia
  5. Hypoglycemia
  6. TIA
  7. Anxiety
73
Q

Circulatory Syncope

  • Circulatory
    • ______: sudden peripheral vasodilation, without increased cardiac output
    • _______: (dehydration, internal bleeding)
    • ________: mechanical reduction of venous return
    • Reduced ___ ____
      • ______ hypotension
      • Arr_____
      • ____ stenosis
      • Hypertrophic cardio____
      • _ _
A
  • Vasovagal
  • Hypovolemia
  • Valsalva
  • CO
    • Orthostatic
    • Arrhythmia
    • Aortic stenosis
    • Cardiomyopathy
    • MI
74
Q

Seizures

Seizure Types

(2)

A

Focal

Generalized

75
Q

Focal Seizures

  • ____ hemisphere
  • C_____ site of onset
  • Usually indicates structural _____ in the cortex
  1. Focal seizure ______ impairment of consciousness
  2. Focal seizure ______ impairment of consciousness
A
  • one
  • consistent
  • lesion
  1. without
  2. with
76
Q

Generalized Seizures

(3)

Other types of seizures

  • p____ seizure
  • psy_____ non-_____ seizure
A
  1. Tonic clonic
  2. Absence
  3. Myoclonic
  • pseudo seizures
  • psychogenic-non-epileptic
77
Q

What type of seizure does this describe?

tonic then clonic; unilateral in hand, foot or face then spread to other body parts on same side

A

Jacksonian (motor)

Focal seizure without impairment of consciousness

78
Q

What type of seizure does this describe?

Numbness, tingling, simple visual, auditory or olfactory hallucinations such as flashing lights, buzzing or odors

A

Sensory

Focal Seizure without impairment of consciousness

79
Q

What type of seizure does this describe?

A funny feeling in epigastrium, nausea, pallor, flushing, lightheadedness

A

Autonomic

Focal seizure without impairment of consciousness

80
Q

What type of seizure does this describe?

Anxiety or fear; feeling of familiarity or unreality; dreamy states

A

Psychiatric

Focal seizure without impairment of consciousness

81
Q

Focal Seizure WITH impairment of consciousness

  • _______ confusion and HA, may remember aura but rest is ______* (they won’t remember having a seizure)
  • May or may not start with ________ or _____ symptoms (if so, called aura)
  • ______ may develop (smacking lips, chewing, walking about)
A
  • Temporary, amnesic
  • autonomic or psychic sx
  • Automatisms
82
Q

Tonic Clonic (grand mal)

  • ​Lose consciousnessly s_____, s______ into tonic extensor r______
  • _____ stops, cyanosis
  • ______ phase follows (rhythmic muscular contractions)
  • Breathing resumes with excessive _______
  • Injury tongue _____ and in_____ may occur
  • ____ictal confusion, drowsiness, HA, fatigue and temporary focal de____
  • No _______ of aura or seizure
A
  • suddenly, stiffen, rigidity
  • Breathing
  • Clonic
  • salivation
  • biting, incontinence
  • Postictal, deficits
  • No remembrance
83
Q

Absence (petit mal or atypical)

  • Sudden b____ lapse of consciousness, with momentary b_____, s_____ or movements of lips and hands but no f_____
    • Petit mal ____ sec
    • Atypical _____ sec
  • No ____ recalled
  • In petit mal, return to _____
  • In atypical, some postictal ______
A
  • brief, blinking, staring, falling
    • <10 sec
    • >10 sec
  • aura
  • normal
  • confusion
84
Q

Atonic

  • Sudden _ _ _ with _____ but no movements
  • Either prompt return to ____ or brief _____
A
  • LOC, falling
  • normal, confusion
85
Q

Myoclonus

  • Sudden brief rapid ____ involving t____ or l____
  • _____ postictal state
A
  • jerks, trunk, limbs
  • variable
86
Q

Major Causes of Seizures in Adolescents (12-20)

  • I______
  • T_____
  • D___ and A____ withdrawal
A
  • Idiopathic
  • Trauma
  • Drug, Alcohol wdrawal
87
Q

Major Causes of Seizures Young Adults (20-35)

  • T_____
  • A____ism
  • Brain _____
A
  • Trauma
  • Alcoholism
  • Tumor
88
Q

Major Causes of Seizures in Older Adults (>35)

  • Brain _____
  • _ _ Disease
  • Metabolic disorders
    • H_____
    • H_____
    • H_____ failure
    • U_____
  • A________
A
  • tumor
  • CVD
    • Hyponatremia
    • Hypoglycemia
    • Hepatic failure
    • Uremia
  • Alcoholism
89
Q

Peripheral Neuropathy

  • _________ = tickling, tingling, burning pricking, or numbness (usually starts in fingertips or toes)
  • Loss of pro_______ or vibratory sense
  • Motor ______ in extremities
  • Loss of deep tendon ______
  • Unsteadiness of ____ (usually ppl have difficulty doing fine motor tasks, buttoning, zipping)
A
  • Paresthesia
  • proprioception
  • weakness
  • reflexes
  • gait
90
Q

Paralysis and Weakness

Intermittent

  • M______ G___
  • Hypo______
  • _ _ _
A
  • Myasthenia Gravis
  • Hypokalemia
  • TIA
91
Q

Paralysis and Weakness

Persistent

  • Sequela of s_____
  • Peripheral n_____
  • _____ neuropathy
  • De______ disease such as MS
  • ______ tissue disorder such as p_____
  • ______ dystrophies
  • G______-B____ syndrome - distal
A
  • stroke
  • neuropathies
  • diabetic ne.
  • Demyelinating
  • Connective - polymyositis
  • Muscular
  • Guillain-Barre
92
Q

Numbness and Paresthesia

  • N____ root _____ due to h____ disc
  • _____ (pernicious)
  • Peripheral n______
  • ______: hypo______, hypo______
  • Hyper______ syndrome
  • Medications (_____)
A
  • Nerve root compression, herniated
  • Anemia
  • neuropathies
  • Metabolic, hypocalcemia, hypomagnesium
  • Hyperventilation
  • Chemo
93
Q

Cause of Neuropathy

Predominantly Motor

  • _____ poisoning
  • G_____-B____ syndrome
  • Acute intermittent p_____
  • Hypo_____
A
  • Lead
  • Guillain-Barre
  • porphyria
  • Hypoglycemia
94
Q

Cause of Neuropathy

Predominantly Sensory

  • D_______
  • Al______
  • Heavy _____ exposure (a____)
  • ___thyroidism
A
  • Diabetes
  • Alcoholism
  • Metal (arsenic)
  • Hypothyroidism
95
Q

Cause of Neuropathy

Mixed Neuropathy

  • ​C_____
  • Ly_____
  • An____
  • Chronic _____ disease
  • Multiple ______
A
  • Carcinoma
  • Lymphoma
  • Anemia
  • liver
  • myeloma
96
Q

Neuropathy Acronym “DANG THERAPIST”

  • D
  • A
  • N
  • G
  • T
  • H
  • E
  • A
  • R
  • P
  • I
  • S
  • T
A
  • Drugs: nitrofurantoin, vincristine
  • Alcohol
  • Nutrition
  • Guillain Barre
  • Toxins: lead
  • Hereditary
  • Endocrine; diabetes, thyroid
  • Amyloidosis (dx similar to MM, hallmark sx is numbness and paresthesia)
  • Renal failure
  • Poryphyria: metabolic d/o caused by altered enzyme activity with the heme biosynthetic pathway
  • Infection: syphilis
  • Systemic disorder; lupus, RA
  • Tumor
97
Q

Upper Motor Neuron Disease

  • Muscle tone will be _____ or sp_____
  • Muscle mass - may have ____ from disuse, otherwise normal
  • Movement - w_____ or p_____ in muscles corresponding to the distribution of damage in the pyramidal/corticospinal tract
  • Reflexes
    • ____reflexia, ankle ____
    • _____ Babinski
A
  • increased, spastic
  • atrophy
  • weakness, paralysis
    • hyperreflexia, ankle clonus
    • Positive
98
Q

Upper Motor Neuron Disease

A
99
Q

Lower Motor Neuron Disease

  • Muscle tone will be ______ or l___ - fl____
  • Muscle mass - may have ____ from disuse
  • Movement
    • Weakness or paralysis corresponding to the distribution of damage in the ____ segment, r___ or _____ nerve
    • F_______
  • Reflexes
    • ____ reflexia
    • ______ Babinski’s
A
  • decreased, lost-flaccid
  • atrophy
    • spinal, root, peripheral
    • fasciculations
  • Reflexes
    • hypo-reflexia
    • negative
100
Q

Lower Motor Neuron Disease

A
101
Q

Stroke/TIA

  • What race >?
  • What gender?
  • (2) types
  • _ _ _
  • ______ -unkown cause
A
  • Black > White
  • Men > Women
  • Hemorrhagic, Ischemic
  • TIA
  • Cryptogenic
102
Q

Signs of Stroke

  • Sudden n____ or w____ of the face, arm, or leg
  • Sudden c_____, trouble s_____ or understanding
  • Sudden trouble ____ in one eye or both
  • Sudden trouble w____< dizziness, or loss of balance or coordination
  • Sudden severe ______
A
  • numbness, weakness
  • confusion, speaking
  • seeing
  • walking
  • HA
103
Q

Signs of Stroke

FAST Acronym

A

F: face drooping (ask to smile)

A: arm weakness (ask person to raise both arms)

S: speech difficulty…

T: time to call 911!

104
Q

Meningitis

  • Can be _____ or ____ etiology
  • What is it?
  • Onset is ____
  • Sx H____, F____, M_____
  • 2 tests
  • N______ R_____
A
  • viral, bacterial
  • inflammation of meninges
  • acute
  • HA, fever, malaise
  • Kernig’s, Brudzinski
  • Nuchal Rigidity
105
Q

Coma

(2)

A

Toxic-Metabolic

Structural

106
Q

Toxic-Metabolic

  1. Patho
  2. Respiratory
  3. Pupils
  4. LOC
  5. Examples
A
  1. Arousal center poisoned or critical substrates depleted
  2. If regular, normal or hyperventilation. If irregular, Cheyne-Stokes
  3. Equal, reactive to light-may be pinpoint from opiates and cholinergic; May be unreactive due to anticholinergic or hypothermia
  4. Changes after pupils change
  5. Uremia, hyperglycemia, alcohol, drugs, liver failure, anoxia, meningitis
107
Q

Structural

  1. Patho
  2. Respiratory
  3. Pupils
  4. LOC
  5. Examples
A
  1. Lesion destroy or compresses brainstem arousal areas, either directly or secondary to more distant expanding masses
  2. Cheynes-Stokes
  3. Unequal or unreactive to light (fixed); Midposition = midbrain; Dilated, fixed = CN III from herniation
  4. Changes before pupils change
  5. Brainstem infarct, tumor, hemorrhage
108
Q

Postures in Comatose Patients

  1. Decorticate (flexor response)
    • ​​Arms adducted to ____, ____ on chest
    • Legs plantar ____, knees _____
    • Associated disruption of lateral cortical ____ tract
  2. Decerebrate (extensor response)
    • ​​Arms ____, p____, wrist ____
    • Legs plantar ____, knees ____
    • Associated with ___ ___ damage
    • Severe ____ disorders such as hypoxia, hypoglycemia
A
  1. Decorticate
    • ​​side, flexed
    • flexed, extended
    • spinal
  2. Decerebrate
    • ​​adducted, pronated, flexion
    • flexed, extended
    • brain stem
    • metabolic
109
Q

Oculocephalic Reflex (Dolls Eye)

  • Assesses _____ functioning
  • Holding ___ lids open so you can see the eyes
  • Move the head ____ to one side and then the other
  • Intact brainstem =
A
  • brainstem
  • upper
  • quickly
  • head turned, eyes move toward opposite direction

Advanced Clinical Assessment (4 decks)

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