Neuro CIS Flashcards
A high fever with tachycardia can cause a ______ in a child secondary to increased cardiac output
Flow murmur
In young children, urine for culture should always be obtained via _____
Catheterization
[so RBC in urine is likely from trauma]
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
Etiologic bacteria that cause meningitis from birth-2 months old
Group B strep (Strep.agalactiae)
E.coli
L.monocytogenes (tx with gentamycin)
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
Etiologic bacteria that cause meningitis in adolescents and young adults
N.meningiditis
Etiologic bacteria that cause meningitis in age>60
S.pneumoniae
L.monocytogenes (tx with ampicillin)
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
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
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
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
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
What can cause CSF protein to be artificially elevated?
Presence of large number of RBCs, as seen in intracranial hemorrhage and traumatic taps
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]
Typical signs of meningitis
HA Fever N/v Nuchal rigidity Photophobia
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
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
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]
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
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
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
- General assessment (mental status)
- Cranial nerves
- Motor (strength, gait, coordination, balance)
- Sensory (dermatomes, pain, temp, position, vibration, Romberg)
- 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
