neurology Flashcards
NON VERBAL SIGNS OF PAIN
- Trouble sleeping
- Tugging at lip
- Unable to ear
- Agitated
- Sleep disturbance
- Changes in behaviour
- Changes in diet - off, avoid hot/cold/hard
- Hands on face/mouth - unusual for them
how to take a history and perfom examinatin if challenging? e.g. alzeheimers
Ask other health care professionals, then relatives
- GDPs, care home, family
- GP summary
If in wheelchair - see in chair - more comfortable. Supported
- Hoist with sling to transfer immobile pt into chair
Plastic mirrors- less likely to break
Bite props
- Mouth props - rest their jaw open
- Finger guards - thimbles - bite on plastic not fully closed
what is this and cause
Angular cheilitis
- Fold of skin
- Poorly fitting denture
- Moist
- Staph aureus
- Candida albicans
treatment options for angular cheilitis
Cream can help
- Antifungals
- miconazole (gel - only local, 4x a day)
- Fluconazole (systemic - interactions - not recommend)
- Fucidin - staph aureus anti bac gel
refit and reline denture
- OVD reduced - need propped open again
Barrier creams - Vaseline to prevent getting damp
recommended antifungal for angular cheilitis
miconazole
gel - only local, 4x a day
fluconazole
systemic antifungal
not recommened for angular cheilitis or denture stomatitis
2 signs of v concerning ulcer
- Raised rolled border
- Feel it - if firm - concern
4 causes of ulcer
- Chemical
- Physical Trauma
- Nutritional deficiency - iron, vita B12, folate, FBC
- stress
how to treat ulcer
get rid of cause
e.g.
- trauma - smooth RR, fix denture fit
- hard to swallow iron tablets or aspirin as dry mouth - replace medication
how to measure ulcer during examination
BPE probe
mucosal sign of dry mouth
glazed glassy appearance on mucosa
clincal tests for dry mouth
Look for
- Pools of saliva - curl tongue up
- Mirror against mucosa - sticks - concern
treatments for dry mouth
saliva stimulators
saliva replacements
advice
saliva replacement options
- oral balance,
- salivix,
- Glodosane – acidic only use if edentulous – not recommended
smooth onto mucosa to make more comfortable
- Can be good whilst doing restorative work to make comfortable on extractions
Some have pork or cow mucins - be aware
advice for xerostomia mangement
regular drinks of plain tap water
cutting down on caffeine
chew sugar free gum
possible causes of dry mouth
- Polypharmacy -compound it
- Drug side effect
Contact GP
Can be really uncomfortable
what is this
Erythematous Palate
Denture stomatitis
- Swollen, sore
common cause of denture stomatitis
candida albicans
remedies for denture stomatitis
- Clean dentures - soak
- Remove at night
- Better fit - realign temporarily
- Antifungal - topical
- miconazole, on fitting surface of denture
- tee tree oil is a natural antifungal
Candida can get into resin - so constant reinfects need new denture
howt to clean denture
Soap - best
- Denture cleaning tablet
- Effervescent tablet - between meals not good only
Warm water - not too hot
Brush
Clean over a bowl of water - so doesn’t smash
overnight storage of denture
out of mouth
Steep in fresh water after cleaning with soap and toothbrush
or
- Baby bottle cleaner - Milton - 20-30mins and not need to rinse
Chlorohexidine - if pure acrylic not metal
toothbrushing advice for carer
Enhanced F toothpaste (high risk caries)
- 2800ppmF duraphat (more common)
- 5000ppmF
Swallowing sensory issues
- SLS free toothpaste
- E.g. Kingfisher - Still has F
Think oral extractions positions
- Lower behind
- Rest in front
2 brush - 1 to retract and 1 to brush
criteria for MRONJ
- Exposed bone for 8 weeks +
- Never had radiation therapy to jaw (osteoradionecrosis)
Refer once the pt showing signs of MRONJ
normal time for extractions to be healed
6 weeks post extractions
80-90% normally healed
MRONJ
medication related osteonecrosis of jaw
- Death of bone when take tooth out
- Uncommon but risk
Infection risk
5 key principles of AWI act
- Benefit
- Minimum necessary intervention
- Take account of the wishes of the adult
- Consultation with relevant others
- Encourage the adult to exercise ‘residual capacity’
what to check if someone says they are POA or WG?
- Ask for paper work from court process
- Read through ensure dental decisions
get AWI from doctor
- Regardless if POA there - she is not able so u or someone else
what to do with RR not causing any symptoms
leave alone?
ask colleagues for second opinion and record asked and there response in notes
3 difficulties often seen with neurological cases
cranial, oromandibular and speech difficulties
common neurological presentations
- Confusion
- Coma
- Memory loss
- Attacks of altered consciousness
- Gait disturbance or imbalance
- Movement problems
- Headache
- Pain or paraesthesia
- Visual loss or change
- Sensory disturbance
- Weakness
- Dizziness
- Problems with speech or swallowing
common neurological disorders
- Dementia
- Multiple sclerosis MS
- Head injury
- Parkinson’s disease
- Neurogenerative conditions (e.g. Huntingdon’s)
- Peripheral neuropathies
- Muscle diseases
- Stroke
- Migraine
- Epilepsy
- Meningitis and encephalitis
- Spinal cord disease
- Neuromuscular disease
- CNS tumours
- Sleep disorders
ptosis
weakness of eyelids
myaeshtenia gravis pathogenesis
autoimmune disorder - antibodies to acetylcholine receptor at post synaptic NMJ
associattion with other autoimmune disorders
may be associated with thymic hyperplasia or thymoma
affects young women in 20s and older men in 70s
myaesthenia gravis investigation and symptoms
antibodies to AChR present in 85% of cases
single fibres EMG and reptitiive nerve stimulation also normal
fatiguable weakness of oclular, bulbar, neck, respiratory and/or limb muscles
- bilateral ptosis
- bilateral facial weakness
- poor cough and neck flexion
- milk fatiguable proximal limb weakness
- slurred speech
- double visison
- difficulty swallowing
myaesthenia gravis management
managed with pyridostigmine (anti-acetylchloine esterase) and immunosuppressive therapies (e.g steroid and IV immunoglobulin)
what is unusual complication of endotracheal intubation
Right side of tongue not working so deviates to right
Atrophy of tongue muscle on that side
muscle and nerve to stick tongue out
genioglossus
hypoglossal nerve CN12
taste sensation of tongue
ant 2/3 CN7
Post 1/3 CN9
motor of tongue
Motor CN12 (All intrinsic and extrinsic)
Bar palatoglossal CNX
what condition
progressive dysarthria to anarthia over 9 months
progressive dysphagia over 6 months
emotional lability and change in personally noted by family members
motor neuron disease
slurred to no speech in 9 months
- unable to move tongue
- poor palatal movement
- tongue is wasted
slowly progressive neurodegenerative disorder
- bulbar – speech and swallowing
- wasting and weakness of facial and mouth muscles
motor neuron disease common presentation
Limb weakness in younger common
25% bulbar onset affecting speech
bacterial meningitis effects
speech and motor difficulties after
e.g. jaw dystonia and dysphagia
- Involuntary jaw opening and retro Collis (backwards head)
- Restriction in neck movements
Chronic neurological effects of brain injury in youth – hypoxic (Cerebral palsy), bacterial meningitis
parkinson’s disease effect on facial muscles
Jaw opening
- not able to close,
- tongue spasm or tremor
- need to use hand to close mouth and struggles to swallow
- need assistance push thumb under chin to trigger tongue to palate
Laboured and high pitch speech
- Can overcome if concentrate
After commencing medication for Parkinson’s disease
Voice returned to normal pitch
benefits of parkinson’s medications on facial muscles
- Not choking
- Less sensitive to tongue spasms
- Voice changed
- More alive and alert to life
When tired/stressed jaw still opens involuntary but feel more control over it
Take medication before food – half hour before so can get more control of life
Not just limbs
hemifacial spasm
rare
fairly continuous right sided facial movements
twitch like - zygomatic, contiunus eye close, nasiolabial fold more ex on right and mouth turned up to right
- Blood vessel Post brain
- Cross brainstem touches nerve roots of CNVII on one side
- Botox
- Protection of nerve roots to prevent
- Sheath over
- Protection of nerve roots to prevent
functional neurological disorder FND
variety of presentation
sometimes psychological origin - neurosymptoms.org
e,g, pic
not normal anatomical position
- speech fine
not facial palsy characteristics - sudden movement to right onset, symptoms intermittent and distractable
abrupt onset
continued for a few weeks after onset
dystonia
involuntary muscle activation
Prolonged prescription – drug induced side effect
Speech, breathing all affected
e.g.
head jerk to the left
left pull of head rather than primary positions
- SCM overactive – turning head to left
Arms unaffected
Unable to straighten left fingers
parkinson progression
slowly progressive neurodegenerative disorder
parkinson treatment
deep brain stimulation surgery
- electrodes deep into brain -subthalmic nucleus
- attach to stimulator - like pace maker
programme stimulation by impulse stimulator
10-15% benefit
