Neuro Block 1 Flashcards
Define Dysarthric
Define Photophobia
D/o or articulation, stammering or stuttering due to a nerve defect
Eye discomfort from brith lights
Define Phonophobia
What is the criteria for alcohol abuse?
Fear of own voice or sounds
1-2 drinks at a time
1-2 drinks a month
Never more the 5 drinks at a time
Define Diplopia
Define Dysphagia
Double vision
Difficulty swallowing
Define Paresthesia
Define Radiculopathy
Define Dyskinesia
Burning, tingling, prickling
Nerves not working (neuropathy) at or near the root
Involuntary movements
What are the red flags of neuro that can’t be missed?
Worst HA of life/thunder clap (hemorrhage/aneurysm)
Sudden blindness (Amaurosis fugax/hypoperfusion of retina)
Back pain worse at night (CA)
Bowel/bladder incontinence (Cauda equine)
SI w/ plans
Define Level of Consciousness
How is Orientation tested for
Awareness of self and environment and rages from awake to comatose
PT states name, location, time of day (day of week and date)
What part of a PTs orientation is FIRST to deteriorate
How is speech assessed?
Time, date, week
Articulation, rate, rhythm and prosody- change in pitch/accentuation of syllables and words
How is language assessed?
What is a typical testing sequence for assessing speech and language
Content of PTs verbal and written output, response to commands and ability to read
Name parts of clothing, watch and pen Repeat “no ifs, ands, or buts” Follow 3 step verbal command Write sentence Read and respond to written command
How are abnormalities of insight or judgement detected during an interview?
What is an example question?
PT describes how they’d respond to situations that have a variety of outcomes
“What would you do if you found a wallet on the ground?”
Types of memory categories and how the info is extracted
Fund of info- history/current events
Insight/judgement- found wallet
Abstract thought- describe similarities
Calculation- subtract by 7s
Define the mini-mental status exam?
What type of score is concerning?
Formal eval tool w/ max of 30pts total
<24/30= suggestive of cognitive d/o
How reliable is a MMSE?
What is it one of the best tests for?
85% and 85% for dementia Dx that is moderate to severe in educated PTs
Mental status of PT, especially as a baseline for future scores
When conducting HEENT exam, testing for other modalities such as corneal reflex and motor part of CN5 is needed when?
What are the 5 movements tested when assessing CN7?
Hx suggests need
Eye brow elevation Forehead wrinkling Eye closure Smiling Cheek puff
Paralysis of the lower half of the face suggests ?
Paralysis of the entire half of the face suggests?
UMN lesion
LMN lesion
What size tuning fork is used to assess CN8?
When/why is the Rinne and Weber tests conducted?
512Hz
Abnormality is detected by Hx or exam
What are the three parts of a motor exam?
The decrease of one of these is indicative of ?
Strength, Tone, Appearance
Dec tone- LMN or peripheral nerve d/o
Pronator drift test is extremely useful for screening for ?
A finding of side, up, searching of withering during this test is indicative of ?
Upper limb weakness- flexion of elbows/fingers, pronation of forearm, especially asymmetrical
Loss of position sense
Define Jendrassik maneuver
What types of movements does this maneuver include?
PT contracts other/distant muscle groups to enhance reflexes during DTR assessment
Inc upper limb reflexes by clenching jaw
Inc Achilles reflex by flexing fingers and pulling them apart
Motor, reflex and sensation of C5
What nerves control the biceps AND brachioradialis reflex?
Deltoid, Bicep tendon, Outter upper arm
C5 and C6
Motor reflex and sensation of C6
Motor, reflex and sensation of C7
Wrist extension, Brachioradialis reflex, lateral forearm (“6-shooter”)
Wrist flexion, tricep tendon, middle finger
Motor, reflex and sensation of C8
What nerves don’t have reflexes associated with them?
Intrinsic hand muscles, no reflex, medial forearm
C8, L5
Motor, reflex and sensation of L4
Motor, reflex and sensation of L5
Tibialis anterior for foot inversion, patellar tendon, medial foot sensation
Extensor digital rum longus, no reflex, middle toes sensation
What nerves in never ate ankle dorsiflexion
Why is this one important to know?
L4 and L5 via peroneal nerve
Crosses head of fibula below the knee and if injured, causes Foot Drop- inability to dorsiflex the foot
Motor, reflex, and sensation of S1
Define the Plantar Reflex
Peroneus longus and brevis muscles, Achilles’ tendon reflex, lateral foot sensation
Normal= plantar flexion of toes Babinski= extensor plantar response from UMN lesion above S1
What cutaneous reflexes are tested for?
Plantar, Superficial Abdomen, Cremaster (L1, L2), Anal (S2-S4)
What are the 4 primitive reflexes
What causes these to appear in adults?
Suck, Root, Grasp, Palmomental- contraction of mental is from ipsilateral scratch across palm
Dz of frontal lobe pathways
Define Dysdiadochokensis
What causes this in adults and kids?
Inability to perform rapid alternating movements
MS in adults
Cerebellar tumors in kids
What is the most important part of the neurological exam?
Why work ups would LPs be obtained?
Walking
Infection, hemorrhage, dementia, CA, MS or ICP
What are the indications to order an LP?
What therapeutic effect does this procedure offer?
Dx infections of meningitis, encephalitis, or sarcoidosis
Reduces CSF pressure
What studies are ordered prior to an LP?
When are the true contraindications for LPs?
Neuroimaging for AMS, papilledema, focal neuro deficit, new onset seizure
Only true contra- Infection at puncture site
WBC count <20K
Lack of consent from PT
What medication causes LPs to be c/i?
What other anti-platelet drugs need to be d/c’d prior to an LP
Warfarin, stop 4-5 days prior or reverse w/ FFP; INR needs to be in range at time of puncture
14 days prior for Ticlopidine 7 days prior for Clopidogrel 10 days prior for ASA 4 days prior for Naproxen 24hrs for ibuprofen
What is it called when CSF is yellow and indicative for a brain bleed?
What site is an LP done at?
Xanthochromia
L3-L4
What is the principle complication of LP?
What population is this s/e common in?
How is this s/e treated?
Positional HA from dec CSF pressure
Inc in Female and Younger PTs
PO analgesics, Caffeine, epidural blood patch
Define an EEG
What are the indications for ordering one?
Non-invasive record of brain activity for suspected seizure/sleep d/os and brain death w/ no contraindications
Seizure, death, Metabolic encephalopathy, Brain lesions, Dementia, Creutzfeldt Jakob, HS Encephalitis, Psychogenic Coma
What is an EMG
What is a NCV
Electromyography
Records intrinsic activity in muscles
Nerve Conduction Study
Stimulates a nerve and records the response
Why are EMGs or NCVs used?
Who can interpret them?
Evaluation of neuromuscular d/o, peripheral neuropathy or entrapment
Neurologist
Physical medicine/rehab providers
What are skull x-rays used for?
What are they usually followed up with?
Evaluate direct trauma (Child abuse), metastasis, calcification or sinus Dzs
CT and/or MRI
What causes the dark/light areas of the CT scan results?
What determines the resolution?
Greater attenuation, high density= white
Soft tissue, poor attenuation= black
Radiation dose, detector size, collimating, field of view and matrix size
CT scans can get images as thin as ? With ? Resolution at ? Speed
What can be added to CT’s for enhanced results?
0.5-1mm w/ 0.4mm in plane resolution at 0.3 seconds per rotation
IV iodinated contrast- shows vascular defects and issues w/ BBB
In a normal CNS, only ? And ? Are enhanced w/ contrast
CTis the primat SOC for evaluating ? Issues
Vessels, and structures lacking BBB: Pituitary, Choroid Plexus, Dura
AMS, focal neuro, acute trauma to brain/spine, subarachnoid hemorrhage, conductive hearing loss
What two studies are used together to evaluate the base of the skull, orbit and Ossetia structures?
What study is used for spinal and intracranial fistula studies?
CT and MR
CT
What imaging modality is used to asses the spinal subarachnoid space in failed back surgery syndromes?
4 indications for CT ordering
CY myelography
Stroke/hemorrhage, Tumor, Trauma, Dementia
What lab results are indicative of contrast nephropathy
Who is more likely to have an allergic reaction to CT contrast?
What previous allergy is not used as an indicator?
SrCr rise of 0.5mg/dL w/in 48hrs of administration
Hx, Atopy (hay fever, asthma)
Shellfish
If an iodinated contrast must be used in a PT w/ allergies, what is given prophylactic
How much radiation exposure is there in a CT brain scan
Glucocorticoids, Antihistamines
2-5 mSv
Any PT getting a CT needs a SrCr measurement if what criteria are present?
A SrCr result can be used as long as it’s within how many weeks?
\+60y/o CKDz, Hx, Transplant DM HTN Paraproteinemia Collagen vascular Dz
6wks
What are the pros of using an MRI
Better for detecting stroke bleeds Acoustic neuroma/pituitary tumor More sensitive for atrophy of dementia Demyelination d/o Edema/infection
What are the complications and c/i with MRI?
Loud/claustrophobia Artifacts from movement Not for unstable PTs No metal implants- accelerated to 150mph Nephrotoxicity
What med can be given to PTs prior to MRIs to relax them?
GFR must be obtained in PTs prior to MRI with what Hx?
Valium
\+60 Renal Dz HTN DM Hepatic Dz
What are Magnetic Resonance Angiography used for?
Image of blood flow
Detects vascular stenosis/occlusion especially in carotid artery bifurcation and Circle of Willis aneurysms
What are PET scans used for?
Perfusion and metabolic activity as a functional imaging study and shows decreased results in dementias
What are myelography used for?
What are the c/is ?
Contrast LP injected into subarachnoid space for evaluating cord compression, AVMs, abscesses and tumors
Tumor/infection at injection site
Bleeding d/o
Inc ICP
Allergy to dye/contrast
What are Carotid US’ used for?
What are the 3 functions of the NS?
Measures blood velocity through carotid artery to bifurcation
Sensory, Integrative, Motor
CNS develops from the ?
PNS develops from the ?
Neural tube- brain and cord
Neural crest- all neural structures outside of the cord
When does the NS begin to develop?
What developmental events occur?
3rd week as the ectoderm/neural plate thickening
Plate folds in forming longitudinal/neural groove
What are the raised edges of the neural plate called?
What is formed when the edges increase in height?
Neural folds
Neural tube
What are the 3 layers of the neural plate?
Outer- marginal, white matter
Middle- mantle, gray matter
Inner- ependymal, lining and ventricles of brain
Define the Neural Crest and what it develops into
Mass of tissue between neural tube and skin ectoderm
Dorsal root/CN ganglia, spinal nerves, CNs, ANS ganglia, adrenal medulla and meninges
When does the neural tube close?
26-28 days after conception (6wks of gestation)
Define Ancencephaly
1:100-, 4x F>M
Failure of neuropore to close, cranial bones fail to develop and brain degenerates
Define Spina Bifida
Failure of posterior neuropore to form, most commonly in sacrolumbar region
SB Occulta at L5-S1 occurs in 10% of population
What two results of the neuropore failure to close a different gestational development times?
How are low and high risks for these issues decreased?
Anencephaly, Spina Bifida
Low- 0.4mg/day started 1mon prior to conception
High- 4mg/day 3mon prior to conception
What are the 4 major parts of the brain
What are the 3 parts of the brain stem
Stem, Cerebellum, Diencephalon, Cerebrum
Oblongata, Pons, Midbrain
What part of the brain is AKA the “little brain”
What is the largest part of the brain and what supports it?
Cerebellum
Cerebrum, deincephalon and brain stem
What does the diencephalon comprise of?
What is the only connection between the L and R hemispheres of the brain?
Thalamus, Hypothalamus, Epithalamus (pineal gland) and Subthalamus
Corpus Callosum
Diencephalon means ?
Cerebrum means ?
Through, Brain
Brain
What functions does the areas of the Cerebral Cortex control and what happens if they’re damaged?
Motor- spastic paresis
Frontal eye field- deviation of eyes to ipsilateral side
Brocas- aphasia
Prefrontal cortex- problem solving/concentration, incontinence
Destruction of orbital portion- inappropriate behavior, words, actions
The frontal lobe is responsible for what roles?
The temporal lobe is responsible for what roles?
Behavior, Emotion, Problem solving, Personality, Reasoning, Primary Motor region, Loss of orientation
Language, Hearing, Short term memory, Olfaction
The parietal lobe is responsible for what roles?
The occipital lobe is responsible for what roles?
Astereognosis
Hemispatial neglect
Inability to copy figures
Visual processing
Shape/color identification
Left sided dominance is better at ? and responsible for ?
Non-dominant is usually right and responsible for ?
Vocal naming
Language, speech, calculation
3D/spacial perception, facial recognition, non-verbal ideation, pointing to a stimulus
Cerebral dominance is determined by the ? test and checks for ?
Wada Test
Aphasia
Ach is released by ? neurons
What are the catecholamines and what do they do?
Mostly PNS, some CNS
Dopamine- emotion, addiction, pleasure, dec in Parkinsons, Inc in Schizo
NorEpi- most common transmitter of post-ganglionic neurons, hypothesized mood s/o
What enzyme breaks catecholamines down?
What are the 3 opioid peptides?
MAOs
Endorphins- B-endorphin 40x more powerful than morphine in hypothalamus
Enkephalines- most distributed, mostly in globus pallidus and reduces pain
Dymophins- same as enkephalines
What are the non-opioid neuropeptides?
Sub-P: pain transmitter in dorsal ganglion, mostly in substantia nigra
Somatostatin- somatotrophin inhibiting factor, regulates release of GH and TSH
Red in Alzeih.
Inc in Huntingtons
What are the two inhibitory AA transmitters
GABA- major inhibitory NT of the brain, activated by Benzos that enhance GABA activity
Glycine- major inhibitory NT of the spinal cord
What are the two excitatory AA transmitters?
Glutamate- major excitation NT of the brain; transmitter of fibers entering the spinal cord/brain, corticobulbar/spinal tracts
Aspartate- transmitter of the climbing fibers of the cerebellum, role in long term memory and can be a neurotoxin
Most common cause of exotoxicity?
O2 deprivation to the brain from ischemic strokes, stimulates nerves to death
Why is Parkinson’s an issue
Degeneration of dopamine neurons in pars compacta of the substantia nigra
Why is Huntingtons an issue
Loss of Ach and GABA neurons in striatum and substantia nigra
Why is Alzeihmers an issue?
Degeneration of cortial and cholinergic neurons in basla nucleus of Meynert and associated w/ +60% loss of choline-transferase in the cerebral cortex
Why is Myasthenia Gravis an issue?
What are 5 Sxs localized to the cerebral functions?
Abs to nicotinic Ach receptors destroys receptors and causes paralysis
Aphasia, Apraxia, Neglect/Extinction, Frontal lobe dysfunction, Affect
Define Aphasia
What are the 2 forms
Inability to speak, deficit of naming (anomia) is single most common finding
Brocas- motor/expressive from frontal lobe (doing)
Wernickes- temporal lobe (sensing)
Damage to Broca’s speech area results in ?
Non-Fluent Aphasia- inability to articulate/form words
Know what they want to say but can’t and speak intelligibly
Depressed, tearful, frustrated
Insight to condition is preserved
Damage to Wernicke’s Area results in ?
Fluent Aphasia- faulty understanding of spoken words.
Word salad- string of good words w/ no combined meaning
Word deafness/blindness or both
Almost all PTs with speech aphasia will have ?
Brocas aphasis is located ?
Wernickes aphasia is located in ?
Agraphia or aphasic in ability to write
B- R hemiparesis
W- R upper visual field defect
Define Apraxia
Inability to carry out purposeful movements in absence of paralysis
A focal disturbance of planning/doing
Define Neglect
What is it AKA
Cortical D/o: R frontal/parietal lobe
Damage to non-dominant hemisphere
Directed inattention or lack of attention to one hemisphere
What are the S/Sxs of Neglect
Completely unaware of anything on one side of body up to denying existence of affected side (fail to shave/shower side of body)
How is Neglect tested for in clinic?
Double stimulation test- won’t feel L side when both sides are touched at same time
Draw test- everything is pushed to R side or only R sided features are drawn
Define Basal Ganglia
What are the parts of this structure
3 nuclei deep in each hemisphere
Globus Pallidus, Putanem, Caudate nucleus= Lentiform= Corpus Striatum
What is the function of the Basal Ganglia
What happens if this area is damaged?
Coordinates motor activity from input from cerebral cortex, thalamus and substantia nigra
Uncontrollable tremors, stiffness and involuntary muscle movements (Parkinson, Huntington)
What is the function of the thalamus?
What crude perception occurs here?
What two nuclei are located here?
Relays almost all sensory input to cerebral cortex; sensory relay and memory pathway
Touch, Pressure, Pain and Temp
Movement planning and control
What does the hypothalamus do?
How is the pituitary gland connected to the hypothalamus?
Over control of ANS, controls pituitary function
Temp, Sleep, Appetite, Sex
Infundibulum
Through the ANS, what functions does the hypothalamus control?
What hormones does the hypothalamus produce?
BP, HR, RR, Temp, Inc Hunger, Thirst, E+/Water balance, Cercadian Rhythm
Oxytocin and ADH
Lesions on the hypothalamus will present as issues with ?
How is the hypothalamus a messenger for the pineal gland?
Appetite, Emotions, Temp and autonomic/endocrine behaviors
Connection w/ pineal gland
Epithalamus consists of the ? gland which controls ?
What structure encircles the upper part of the brain stem and corpus collosum?
Pineal gland- regulation, secretion of melatonin, serotonin and NorEpi
Limbic system
Limbic system is made up of ?
What does it control?
Amygdala, Cingulate Gyrus, Midbrain Raphe, Locus Ceruleus, Hippo Campus
Affective/Emotional brain- emotion, eating and reproduction
Seizures arising from the amygdala are perceived/felt as ?
Where is the amygdala
Fear
Deep in temporal lobes
What is the Amygdalas function
An enlarged amygdala is found in ? d/o
Chief role- Memory of emotional experiences
Central- behavior response to fear
Autism
What does the Hippocampus do?
What part of the brain is it closely connected with?
Integrator of incoming novel/unpleasant stimuli
Connects w/ temporal lob
What unique ability does the hippocampus have?
What is the make up of the “little brain”
Predicts next event based on what has already happened
Cerebellum- 10% of volume, 50% of CNS neurons
2 hemispheres/10 lobes
What is the blood supply to the cerebellum?
Cerebellum occupies the ?
Sup Cerebral Artery,
Ant Inf Cerebral Artery, Post Inf Cerebral Artery
Posterior Fossa, AKA posterior circulation
What are the 3 fold functions of the cerebellum
Sensory perception, coordination, motor control
No paralysis
Feedback d/o- posture, equilibrium, motor learning
Ataxia- posterior fossa localizing condition; inability to have posture
What chemical inhibits the activity of the cerebellum?
What are the 3 parts of the brain stem and rules that apply here
Alcohol
Midbrain, Pons, Medulla
Ant- motor
Post- sensory
Tracts responsible for movement all pass through ?
What two centers are found here?
Midbrain
Pyramidal- voluntary
Extra pyrimidal- involuntary
Reticular Activating System and respiration/consciousness center
Where does the spinal column start and end?
What are the two types of matter found?
Medulla to L1-2
Gray- nerve cell bodies
White- mylenated nerves
? and ? roots travel the longest to fan out at ? to form the Cauda Equina
Motor pathways of the UMN begin ? and travel down the spine to synapse with ?
Lumbar and Sacral
L1-2
Cortex and brain stem
Anterior horn cells
LMN begin in the ? w/ the axons traveling directly to ?
These carry info to the ?
Anterior horn
Muscle fibers
Neuromusclar junction
Each spinal nerve is formed with the union of ?
Dorsal- convey sensory axons afferent signals towards spinal cord
Ventral roots- motor axons efferent/away from CNS to skeletal muscles and visceral/glands
What are the 3 de/ascending fibers that connect the CNS with the PNS
Corticospinal tract- voluntary motor activity
Spinothalmic tract- pain and temp
Dorsal columns- vibration, position, light touch
Corticospinal pathway is AKA ? and controls ?
Where does it originate?
Motor pathways
Voluntary movements, integration of complicated movements
Cortex
Corticospinal tract descending is AKA ?
Where does it cross?
Where does it terminate
Pyramidal tract
Medulla
Anterior horn cells
What are the two ways sensory impulses ascent the spinal tract?
What are the crossing and end points for these paths?
Dorsal column- ascend up same side as fibers entering the cord and cross midline at the medulla
Spinothalamic- crosses midline immediately and ascends to thalamus on the opposite side
What type of PE findings would be seen in PTs w/ a lesion on their spinothalamic column?
What is the simplest unit of sensory and motor function and what is the sequence of events??
Loss of pain, temp, sensory on contralateral side below site of lesion
Monosynaptic reflex arc- tapping tendon, sensory fibers in partially stretched muscle, sensory impulse, peripheral nerve, spinal cord, anterior horn, NM junction, contraction
10:00-10:30 lect 3
Summary pathway of motor, dorsal and spinothalamic tracts and what is seen if there is a lesion there?
Motor- crosses at medulla, goes down lateral corticospinal tract; ipsilateral Sxs
Dorsal- vibration, position, light tough go up and crosses at medulla; ipsilateral Sxs
ST- pain/temp immediately cross and go up; contralateral Sxs
Arterial blood supply to the brain comes from what two supplies
Each supplier then provides blood for what lobes?
Internal carotid- anterior/middle cerebral- frontal, parietal, lateral temporal= “devastating” strokes
Vertebral arteries- posterior basilar, occipital, medial temporal lobe, cerebellum- TIAs= drop attacks
What are the consequences of a block in the anterior and middle cerebral artery and basilar artery?
Anterior- lower limb area of motor cortex
Middle- face and upper limb, language hemisphere
Basilar- L/R PCA, occlusion leads to drop attacks, complete occlusion at junction= blindness
What is the posterior circulation of the brain stem?
What layer of the meninges extends through the entire CNS?
SCA, PICA, AICA, Basilar artery
Dura (Out to in= Dura, Arachnoid, Pia)
Where is CSF created and absorbed?
Define Cranium Bifidum
Choroid plexus
Subarachnoid space
Defect in occipital lobe, provides area for meninges, cerebellar tissue and 4th ventricle to herniate through
ANS fibers exit the spinal cord at ? level
Where to PNS fibers exit?
T1-L2
CN 3, 7, 9, 10
S2-4
What is the master control of the ANS?
What is the function of the PNS
Hypothalamus
Carry impulses to/from cord through 31 pairs of nerves
8C, 12T, 5L, 5S, 1C
Define Sensory Dermatomes
Why are these helpful?
Band of skin innervated by sensory root of a single spinal nerve
Used in localizing neurolgical lesions
What are the basic parts of a neuron?
What are the functions of these parts?
Cell body
Fibers- axon and dendrites
Dendrites- short/branched receiving portion
Axon- propagates impulses to other cells, can be 3ft long
There is virtually always _ axons(s) per neuron
Axons arise from __ on cell bodies
One
Hillock
What is the first part of an axon called?
Where do APs arise from?
Initial segment
Trigger zone- junction of hillock and initial segment
Define Synapse
Junction between two neuron or between neuron and effector
What are the 4 events that occur at a chemical synapse
1- impulse arrives
2- depolarization opens Ca channels and causes outflow
3- Inc Ca causes exocytosis of NT into cleft
4- NT travel and bind w/ post-synaptic neuron
5- Na travels and creates post-synaptic potential
6- nerve impulse triggered
What type of myelin sheath is on PNS and CNS?
Impulse velocity depends on ?
PNS= Schwann cells CNS= oligodendrocytes
Diameter
Voltage gated channels are only present at ?
What do these structures allow?
Nodes of Ranvier
Increased transmission speed w/ less energy
What are the 7 questions asked during a PT approach with a neuro issue?
System Distribution Nature of sensory involvement UMN involvement Temporal evolution Evidence of hereditary Associated medical condition
Define Mononeuropathy: Unilateral Peripheral Neuropathy
From trauma/compression
Rads: electroDx to assess demyelination/axonal degeneration
If caught early, transient
Legal limit for driving DUI is ? level of alcohol?
What level is lethal?
80mg
350-900mg
Alcohol intoxication is manefested by ? and indicated a blood alcohol elvel of ?
Ataxia, Dysarthria, N/V
> 150mg
Define Chronic Alcohol Brain Syndrome
What other issue can this be associated w/ ?
Encephalopathy that has erratic behavior, memory issues and emotional instability
Wernicke-Korsakoff syndrome
What is the most common complication of DM?
DM is also the most common cause of ? in developed countries
Diabetic neuropathy
Peripheral neuropathy
What is the most common form of diabetic peripheral neuropathy
What is the first sensory involvement seen?
Distal Symmetric Polyneuropathy
Stocking-glove pattern
What test is done for distal symmetric polyneuropathy
A biopsy can be done to look for ?
Filament test
Axonal degeneration
What is the other form of diabetic neuropathy
How is diabetic neuropathy treated?
Autonomic neuropathy- OHOTN
Sweating disturbance
Strict glycemic control
Pain control- TCA, Gaba, S/NRI, Capsaicin
What two meds can offer pain relief from diabetic neuropathy in the first 72hrs?
What med is used if the first one fails to provide relief?
Nortriptyline, Desipramine
Gabapentin/Pregabalin
What annual exam do diabetics need to have on their feet?
Monofilament test and Dilated eye exam
Presentation of HIV neuropathy can be affected by ?
Late stages of this form needs to be distinguished from ?
Highly Active Anti-Retroviral therapy
Toxic form related to nucleoside analogue Tx
What is a late stage of HIV Neuroapthy that would involve ortho?
How is this issue treated?
Cauda equina from Cytomegalovirus
Ganciclovir
What causes Lyme Dz and what carries it?
What makes this presentation unique from Bells Palsy?
Borrelia Burgdoferi from Ixodes Deer tick
Bilateral in half of cases
S/Sxs Lyme Neuropathy
How is it Tx
Migratory joint pain
Doxy 100mg
ABX if severe
What causes Leprous Neuritis
Where does it come from and how is it transferred?
Chronic infection from acid fast bacilli Mycobacterium Leprae
SE Asia, Africa, South America
Respiratory, dirt, insects
What are the S/Sxs of Leprous Neuritis
What are the two presentations
Affects cooler areas of skin as anesthesia and motor abnormalities
Macular/nodular skin lesion that is pale or erythematous
Lepromatous- symmetric nerve involvement, more extensive
Tuberculoid- asymmetric, confined to skin/peripheral nerves
How is Leprous Neuritis Dx confirmed?
How are the two forms treated?
Biopsy and acid-fast stain
Lepromatous- Rifampin, Clofazimine and Dapsone
Tubercloid- Rifampin and Dapsone
Autonomic Neuropathy is AKA ?
Where does it effect?
Dysautonomia
Peripheral autonomic nerves
What usually precedes Autonomic Neuropathy
What are the S/Sxs
Viral Prodrome
Post HOTN, Anhidrosis, Hypothermia, Dry mouth/eyes
Define Pure Motor Neuropathy
What does it present with?
Affects any level of motor neuron
Weak, denervation, atrophy, fasciculations
Define Pure Sensory Neuroapthy
Why is this form dangerous
Common
Large/small afferent fibers
Poor prognosis and no recovery
Define Plexopathy
How does the Cold cause neuropathy
How is it treated
Brachial or Lumbosacral plexus as motor and sensory deficits; usually from trauma
Cutaneous vasomotor instability causing axon degeneration of myelinated fibers
Tx Sxs
Define Trophic Changes
How does it present
Observable changes in body structures from denervation
Skin break down and poor healing
How long for peripheral neuroapthy to regenerate?
When does healing process begin
2mon to more than a year
Removal of toxin
Return to normal metabolic rate
What is the most common type of hereditary neuropathy?
Charcot Marie Tooth Dz, autosomal dominant presents as foot/gait abnormality
Distal weakness starting in legs and spreads to hands and forearms
Inverted champagne bottle legs
Type 1- most common, demyelination
Type 2- axonal loss
How is Charcot Marie Tooth Dz treated?
PT/OT- ankle-foot orthotics
Rare to lose ability to ambulate
How does HSAN present
Distal sensory loos w/ burning/aching pain
Dermal ulcerations
Foot/hand deformities
Bladder dysfunction and reduced foot sweating
What kind of gene mutation causes Familial Amyloid Polyneuropathy
How does it present
Tranthyretin gene
Painful paresthesis and early ANS involvement
Cardiomyopathy leads to HF
How is Familial Amyloid Polyneuropathy treated?
Liver transplant
Define Refsum’s Dz
What is the classic tetrad for this Dz
Earliest Sxs= night blindness
Progressive sensorimotor demyelingating neuropathy
Peripheral neuropathy
Retinitis pegmentosa
Cerebellar ataxia
Inc CSF protein level
How is Refsum’s Dz Dx?
How is it treated
Phytanic acid in urine and serum
Avoid phytanic acid, plasmaphoresis
What is the most common variant of Guillain Barr Syndrome
What microbe infection is this Dz associated with?
Acute Inflammatory Demylination Poly.
Campylobacter Jejuni
How does GBSyndrome present
What will lab results show of an LP?
Weak legs that ascends
Max paralysis in 2wks
Areflexia
High protein, normal cell count
How is GBSyndrome Tx
Since it’s a self limiting d/o, what is the most common residual issue?
IV Immunoglobulin
Plasmaphoreisis,
ICU admit
Fatigue
What drugs are used for CIPD
How does Multiple Myeloma present on x-ray and EDx studies
Azathioprine, Methotrexate, Cyclosporin, Cyclophosphamide
Lytic/osteoprotsis lesions
Consistent w/ axonal degeneration
How does vascultitic neuropathy present
When is a high degree of suspicion needed
Multifocal asymmetric motore snesory neuropathy from ishemic lesion on nerve trunks/roots
Subacute/chronically evolving mononeuropathy multiplex occurs w/ constitutional sxs
What are the hallmarks of Myasthenia Gravis
What types of lab results will show?
First- diplopia, ptosis
Weak respiratory muscles
Worse Sxs at end of day
Improve w/ rest
ACh receptor Abs in blood
Impaired EMG/NCV transmission
What can a CT scan of myasthenia gravis Pts show?
How is it tested for to Dx?
Thymoma- thymic medullary cells that synthesize anti-Ach receptor Abs
Ice-Pack test
Tensilon Test- give Edrophonium 2mg given to Pts w/ negative Ab and EDx testing
Tensilon pos if weakness improves
How is Myasthenia Gravis treated?
Anticholinesterase drugs- Pyridostigmine Generalized MG= thymemctomy Corticosteroids- Prednisone Plasmapheresis
What is Myasthenic Syndrom (Lambert-Eaton) associated w/?
Small cell carcinoma
P/Q type Ca channel Abs causing weakness in proximal limb muscles
How does Myasthenic Syndrome differ from MG?
How is it treated?
What med gives poor results?
Power increases w/ sustained contraction
Prednisone
Anticholinesterase drugs
Consider Botulism poisoning in kids under 1yr if the present with ? Sxs?
D/os associated with Aminoglycoside use is common with what two offending agents?
Constipation, Poor feeding, Failure to thrive w/ progressive weakness
Gentamicin
Streptomycin
How does Tetanus exert it’s effect?
What are the presenting Sxs?
Irreversibly binds to receptors in brain/spine blocking GABA release
Trismus
Risus Sardonicus- facial muscle contortion
Opisthotonis- hyperextended posturing
How is tetanus treated?
How do nerve agents exert their effect?
Human tetanus immune globulin 500units
Metronidazole- preferred ABX
Benzos
Cholinesterase inhibition, prevent ACh from being destroyed causing over stimulation
