Neuro CIS Flashcards by Sarah Gillen

A high fever with tachycardia can cause a ______ in a child secondary to increased cardiac output

Flow murmur

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In young children, urine for culture should always be obtained via _____

Catheterization

[so RBC in urine is likely from trauma]

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What does it mean to have an elevated WBC with left shift?

Indicates the presence of infection

Left shift occurs when immature neutrophils (bands) are pushed out of the marrow to fight something

The I/T (immature/total neutrophils) ratio can be helpful in determining presence of infection; if greater than 0.2, it is likely that infection is present

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Etiologic bacteria that cause meningitis from birth-2 months old

Group B strep (Strep.agalactiae)

E.coli

L.monocytogenes (tx with gentamycin)

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Etiologic bacteria that cause meningitis in age 2 months-12 years

S.pneumoniae (gram+ diplococci)

N.meningitidis (gram- diplococci)

H.influenzae (gram- coccobacilli) — less cases since vaccination

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Etiologic bacteria that cause meningitis in adolescents and young adults

N.meningiditis

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Etiologic bacteria that cause meningitis in age>60

S.pneumoniae

L.monocytogenes (tx with ampicillin)

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The ____ and ____ vaccines have decreased the incidence of meningitis in children in all age groups except those less than 2 months of age

HiB; S.pneumo

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CSF findings with bacterial meningitis

[opening pressure, WBC, PMN, glucose, protein, gram stain, cytology]

Opening pressure >300 mmHg (nml <170)

WBC >1000/mm3 (nml <5 monos)

PMN >80% increased

Glucose decreased

Protein increased

Gram stain POSITIVE (+0)

Cytology negative

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CSF findings with viral meningitis

[opening pressure, WBC, PMN, glucose, protein, gram stain, cytology]

Opening pressure <300 mmHg (nml <170)

WBC <1000/mm3 (nml <5 monos)

PMN 1-50% increased

Glucose normal

Protein normal or slight increase

Gram stain negative

Cytology negative

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Neoplastic CSF findings

[opening pressure, WBC, PMN, glucose, protein, gram stain, cytology]

Opening pressure 200 mmHg (nml <170)

WBC <500/mm3 (nml <5 monos)

Glucose decreased

Protein increased

Gram stain negative

Cytology POSITIVE

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CSF findings with fungal etiology

[opening pressure, WBC, PMN, glucose, protein, gram stain, cytology]

Opening pressure 300 mmHg (nml <170)

WBC <500/mm3 (nml <5 monos)

PMN 1-50% increased

Glucose decreased

Protein increased

Gram stain negative

Cytology POSITIVE

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What can cause CSF protein to be artificially elevated?

Presence of large number of RBCs, as seen in intracranial hemorrhage and traumatic taps

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While there are no absolute contraindications to an LP, when should careful consideration be taken?

When there is strong suspicion of increased intracranial pressure, coagulation abnormalities, or suspicion of a spinal epidural abscess

[consider a CT prior to LP in patients with significantly altered mentation, focal neurologic signs, papilledema, hx of a seizure within previous week, or impaired cellular immunity]

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Typical signs of meningitis

HA
Fever
N/v
Nuchal rigidity
Photophobia

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How do you test kernig sign

Flex pts leg at both hip and knee and then straighten knee

Positive = extension of leg at knee when hip is flexed to 90 elicits PAIN

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How do you test for brudzinskis sign

As you flex neck, watch hips and knees in reaction to your maneuver

Positive = flexion of neck elicits flexion at hips

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When should fontanelles be checked?

In patients <2 y/o (anterior fontanelle is last to close around age 2)

[In a 3 yr old child, fontanelles will be closed and sutures are fused; the “typical” signs of ICP that coincide with meningitis will be present]

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in suspected meningitis, Abx should be started as soon as labs have been drawn, with the option to tailor the medications later. What abx should empirically be given?

Vancomycin + Ceftriaxone

Add ampicillin if age 50+ and concerned for Listeria

Add acyclovir if suspicious of HSV encephalitis

Can add dexamethasone

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Why do some docs choose to use Dexamethasone prior to abx for meningitis?

There is evidence that shows that administration of steroids PRIOR to abx can decrease hearing loss and neurological sequelae — depends on preference of physician if this is prescribed

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SIADH is a disorder of impaired water excretion caused by inability to suppress the secretion of ADH; if water intake exceeds the reduced urine output, the ensuing water retention leads to development of ______

Hyponatremia

In most adults, a fever is:

Oral temp above _____

Rectal or ear temp above _____

100.4 (38 C)

101 (38.3)

A child has a fever when rectal temp is _____ or higher

100.4 (38C)

General causes of fever

Infection — Most common

Medicines (abx, opioids, antihistamines, etc)

Severe trauma or injury (MI, stroke, heatstroke, burns)

Other conditions: arthritis, hyperthyroid, DVT, cancers like leukemia and lung cancer

Which of the following is the most accurate way to measure temperature? ``` A. Rectal B. Oral C. Armpit D. Bladder E. They are all the same ```

D. Bladder — used in critically ill patients via foley catheter with probe Typically most accurate way is rectal temp — closest to core temp. A rectal or ear temp will be slightly higher than oral reading; armpit temp with be slightly lower than oral reading

OMM considerations for meningitis

Contraindicated in acute setting Once pt is stable and on abx, consider: Lymphatics (rib raising, ST to C-spine, Venous sinus drainage) Gentle techniques on C-spine BLT to lumbar spine (careful of LP area!)

5 essential components to neuro exam

1. General assessment (mental status) 2. Cranial nerves 3. Motor (strength, gait, coordination, balance) 4. Sensory (dermatomes, pain, temp, position, vibration, Romberg) 5. Reflexes (DTRs, cutaneous reflexes, pathologic reflexes)

Modes of evaluating mental status

Level of alertness Appropriateness of response Orientation to person, time, place Congruency of mood

Locations of CN in brain

Telencephalon: I Diencephalon: II Midbrain: III-IV Pons: V Pontomedullary junction: VI-VIII Medulla: IX-XII

What score on snellen chart is legally blind?

20/200

Pupillary light reaction checks which CNs?

Sensory CN II Constriction CN III

Trigeminal motor function can be assessed by palpating temporal and masseter mm and asking pt to clench their teeth while you note the strength of contraction. Ask pt to move jaw side to side, testing lateral pterygoids Unilateral weakness with this indicates a _____ lesion in CNS Bilateral weakness with this indicates ______ _____ disease d/t bilateral cortical innervation

Pontine Cerebral hemispheric

CNS patterns of stroke — where is the lesion: Facial and body sensory loss on same side

Contralateral cortical or thalamic lesion

CNS patterns of stroke — where is the lesion: Ipsilateral face but contralateral body sensory loss

Brainstem

Condition affecting the facial n. —-> upper and lower face affected, loss of taste, hyperacusis, increased or decreased tearing

Bell’s palsy

A central lesion to facial nerve affects mainly the ____ part of the face

Lower

Facial features that indicate weakness caused by CN VII lesion

Widened palpebral fissure Nasolabial fold

Methods for testing CN VIII

Whisper test Weber’s test — diminished tone in affected ear indicates sensorineural loss; louder tone in affected ear indicates conductive deafness Rinne test — if tone is not heard once removed from mastoid process, it is conduction deafness

Nerve segments associated with UE strength testing: elbow flexion/extension, wrist flexion/extension, hand grip, finger abduction, opposition of thumb

Elbow flexion (C5, 6); extension (C6,7,8) Wrist flexion/extension (C6-7) Hand grip (C7-8, T1) Finger abduction and opposition of thumb (C8, T1)

Nerve segments associated with LE strength testing: hip flexion, extension, adduction, and abduction

Hip flexion — L2-4 (psoas and iliacus) Extension — S1–glut max Adduction (L2-4) Abduction (L4-5, S1)

Nerve segments associated with LE strength testing: knee flexion and extension

Knee flexion — L4-5, S1-2 — hamstrings Extension — L2-4 — quads

Nerve segments associated with LE strength testing: ankle plantar and dorsiflexion

Ankle plantar flexion — S1-gastroc Dorsiflexion — L4-5 tibialis anterior

Methods of gait testing

Walk down hall and turn back — look for posture, balance, swinging arms, normal balance, smoothness, instability = ataxia Tandem walking may reveal ataxia Walk on toes then heels — tests plantar vs. dorsiflexion of ankles, as well as balance

An inability to walk on one’s ____ may indicate CST damage

Heels

Cerebellar function tests

Rapid alternating movements Finger-to-nose Finger-to-finger Heel to shin Pronator drift **Abnormal tests = dysdiadokinesias**

Test used for proprioception

Move fingers and toes with pts eyes closed, have them track movement

Dermatomes associated with: ``` Shoulder top Radial aspect of forearm Little finger Nipple line Umbilicus Great toe Posterolateral calf/little toe ```

Shoulder top = C4 Radial aspect of forearm = C6 Little finger = C8 Nipple = T4 Umbilicus = T10 Great toe = L5 Posterolateral calf/little toe = S1

Nerves tested with biceps, triceps, brachioradialis, patellar, and achilles

Biceps (C5,C6) Triceps (C6,C7) Brachioradialis (C5,C6) Patellar (L2,L3,L4) Achilles (S1)

In general: Hyperactive reflexes = _____ lesion Hypoactive reflexes = _____ lesion

CNS PNS

Cutaneous simulation reflexes

Abdominal — T10-T12: see contraction of abs w/ deviation of umbilicus toward stim Cremasteric reflex — Afferent L1, efferent L2 Plantar response — L5,S1 Anal reflex —S2-S4

Describe plantar response with babinski sign

Normal response to plantar surface stroke should be plantar — dorsiflexion of big toe and fanning of toes is + and suggests UMNn dysfunction