FNP III Neuro P1
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Differentiate between dizziness and vertigo?
Vertigo is the sensation of rotation or movement of the patient or patient surroundings. Vertigo may result from an inner ear disease or disturbance of the vestibular center pathway in the CNS.
Dizziness is the sensation of unsteadiness and a feeling of movement within the head. Dizziness is described as a feeling of lightheadedness, weakness, or faintness. Dizziness occurs as a result of inadequate blood flow and oxygen supply to the brain and spinal cord.
Describe the categories for classifying dizziness?
Differential diagnoses for dizziness are classified into 4 categories: peripheral vestibular disease, systemic disorders, CNS disorders, and anxiety states.
What are the most commonly prescribed medications for vertigo and why do they work?
Antihistamines such as Benadryl Phenergan and meclizine of the most commonly prescribed medications for vertebral. These agents suppressed the vestibular and organ receptors in inhibit activation of bagel responses.
What are key points to assess during a physical examination for dizziness or vertigo?
- Examination of the inner ear to rule out cerumen impaction or otitis media, hearing tests, and the Hall Pike maneuver.
- The Hallpike maneuver is performed by rotating the patient's head to one side than lowering it slowly to 30° below the body line. The patient should be observed for nystagmus during had rotation and vertical positioning. In patients with benign vertigo there may be rotational nystagmus and possible severe vertigo which usually occurs in one direction. This resolves quickly and should not be reproduced after 2 or 3 repetitions. The clinician should suspect a central lesion when the vertical nystagmus is of longer duration and continues with each repetition.
Paresthesia is an abnormal sensation described as numbness or tingling, cramping, or pain without unknown stimulus, felt along peripheral nerve pathways.
Paresis is weakness.
What disease process may be present with the stocking glove distribution pattern bilaterally?
If the patient has diabetes, symptoms of diabetic neuropathy such as bilateral loss of pain sensation and diminished touch, temperature sensation, and proprioception may be present. They may present in a stocking glove distribution
Describe the difference between a resting tremor and an intentional tremor?
And resting tremor occurs in a relaxed and supported extremity and ends with purposeful movement, whereas an intentional tremor occurs when the patient attempts voluntary movement.
Describe the classification of a partial seizure?
When there is no loss of consciousness, the seizure is classified as a simple partial seizure. Simple partial seizures usually have unilateral hemispheric involvement.
When consciousness is impaired the seizure is classified as a complex partial seizure. Complex partial seizures, have bilateral hemispheric involvement.
What is an automatism?
Automatism's are aberrations in behavior, such as chewing swallowing mimicry, crude, or elaborate.
Describe generalized seizures?
Generalized seizures are those in which the 1st clinical changes indicate initial involvement of both hemispheres of the brain.
Motor manifestations are bilateral, as our EEG patterns.
Describe an absence seizure?
The hallmark of an absence seizure is a sudden onset, interruption of ongoing activities, a blank stare, and possibly a brief upward rotation of the eye.
Describe tonic-clonic seizures?
Tonic-clonic, or grand mal seizures are the most frequently encountered generalized seizures. There is a sudden, sharp tonic contraction of muscles, Stridor, or cry and then the patient falls to the ground in the tonic state.
Myoclonic jerks are sudden brief shock like contractions which may be generalized or confined to the face and trunk or to one or more extremities.
Pseudo-seizures are associated with seizure like symptoms but are not associated with EEG changes. Up to 80% of pseudo-seizures are associated with early sexual abuse, especially in females.
When is the greatest risk for a 2nd seizure?
The risk of recurrence is greatest in the 1st 2 years, so if treatment is initiated, it probably can be halted after the highest risk period is over.
Describe Lou Gehrig's disease?
Also known as amyotrophic lateral sclerosis (ALS) is a progressive neurologic disorder that involves destruction of the anterior horn motor cell in the spinal cord or brain stem.
Unlike MS the symptoms are symmetrical. It may present with a simple gait disturbance by weakness or a change in voice.
The diagnosis is made by EMG study and there is no treatment for ALS.
What are the 4 types of MS?
Relapsing -- remitting: characterized by acute attacks with either full recovery or some residual deficits between episodes.
Primary progressive -- steady disease progression, with possible plateaus and remissions.
Secondary progressive-- a combination of the 1st 2 types, beginning as relapsing remitting disease but then slowly acquiring primary progressive characteristics.
Progressive relapsing -- is a progression of the disease on a steady downhill course, as compared to the relapsing remitting variety, progression may not stop at any point.
Describe good prognostic indicators of MS?
Good prognostic indicators include minimal disability after 5 years of onset, complete and rapid remission of initial symptoms, onset at age 35 or younger, only one symptom during 1st year, acute onset of for symptoms, brief duration of most recent exacerbation, long 1st remission, optic neuritis or sensory symptoms.
Describe poor prognostic indicators of MS?
Poor prognostic indicators include late onset, chronic progressive course, motor symptoms, Polly symptomatic onset, and vertigo.
After 15 years, 50-60% of patients with MS remain ambulatory, 10 to 20% need assistance to walk, 15 to 30% are bedridden.
What are the most common presenting symptoms of MS?
The most common presenting symptoms in MS include sensory disturbances of the extremities, spasticity and weakness of the legs, bladder and bowel dysfunction, ataxic gait, paresthesias in the extremities, fatigue, optic neuritis, and trigeminal neuralgia.
What should you be suspicious of if a young person develops trigeminal neuralgia?
The diagnosis of MS should be considered whenever a young adult develops trigeminal neuralgia.
A sensation of electricity down the back after passive or active neck flexion is called ______?
Describe making the diagnosis of MS?
CNS involvement of multiple systems must occur in one of the following patterns: 2 or more episodes of exacerbations, separated by one month or longer and lasting more than 24 hours with subsequent recovery.
What tests are useful in diagnosing MS?
A lumbar puncture evaluation of CSF for the presence of new goblins, lymphocytes, and oligoclonal IgG bands.
An MRI is a sensitive, objective measure of plaques used to measure the outcomes of treatments. Periodic recording of the volume and number of lesions detected in the brain by MRI can assist the clinician in monitoring the extent of the disease.
What are the goals of management of MS?
- 1. Delay the progression of the disease
- 2. Manage chronic symptoms
- 3. Treat acute exacerbations
What drugs are useful in treating MS?
1. Corticosteroids: mainstay of treatment, have an immunomodulatory and anti-inflamatory effect.
Patient with RELAPSING-REMITTING MS the treatment of choice is interferon1a or 1b.
What is Parkinson's disease?
Parkinson's disease is a chronic, progressive, degenerative disorder of the basal ganglia in the CNS.
Degenerative disease of the motor systems of the brain.
It's neurological effects include tremor at rest, muscular rigidity, slow movements, and difficulty maintaining a steady posture.
Typically, the motor problems of Parkinson's disease improve when a patient is treated with levodopa.
Describe the categories of Parkinson's disease?
- Parkinsonism has 4 catagories:
- 1. Idiopathic
- 2. Symptomatic
- 3. Parkinson -- plus syndromes
- 4. heredodegnerative disease processses
Describe Parkinson-plus syndrome?
Parkinson-plus syndrome referred to as secondary parkinsonism when there is a known cause for the disorder such as cerebral vascular disease, drugs, infections, or exposure to toxins.
Describe the pneumonic TRAP as it relates to Parkinson's disease?
Describe a classic presentation of PD?
- T = tremor at rest
- R = rigidity
- A = akinesia or brady kinesia
- P = postural disturbances
A characteristic motion of the thumb and forefinger called pill rolling.
Describe the state of rigidity in Parkinson's disease?
Describe the freezing phenomenon?
Rigidity is equal in all directions and is usually manifested by cogwheeling, a ratchet like, rhythmic contraction, especially in the hand and passive stretching.
The freezing phenomenon also called motor block is a transient inability to perform active movements in Parkinson's disease.
What are clinical and laboratory clues that suggest the patient was parkinsonism may have some form of the syndrome other than PDA itself?
PD often manifests with unilateral symptoms, whereas symptomatic parkinsonism or Parkinson-plus syndromes usually have symmetrical symptoms.
Levodopa may be given a trial basis and is one of the most important diagnostic aids is the patient's response to levodopa. Patients with PD usually have a satisfactory response to levodopa while other forms of parkinsonism are most likely if there's no response to levodopa.
Differentiate between PD and essential tremor?
PD is commonly mistaken for essential tremor, which is characterized by postural and kinetic tremor not resting tremor.
Describe the principle management of PD?
The principle management of PD is to control the symptoms because no drug or surgical approach prevents the progression of disease.
The major decision is when to introduce levodopa. Since levodopa can improve symptoms by 40 to 50% but subjects the body to increased free radicals consideration must be given to things like employment and ADLs.
The rule of thumb is to administer and lowest dosage of levodopa that brings adequate system reversal.
What is also Alzheimer's disease?
Alzheimer's disease is a progressive, neurodegenerative condition and the most common form of dementia in the older population.
AD is a progressive irreversible cortical disconnection syndrome.
To pathologic lesions are found in large numbers throughout the brain of Alzheimer's patient; neuritic plaques (also called senile plaques) and nurofibrillary tangles.
What is the initial presentation of A.D.?
The patient usually presents with complaints of memory problems. Getting lost in familiar places inability to accomplish demanding tasks at work or increasing the slow response to any cognitive challenge. Word finding difficulty usually occurs.
How is the Mini mental State exam used to qualify Alzheimer's patients?
Within the possible scoring range of 0 to 30 the median score for adults age 18 to 59 is 29, but the median score drops to 25 at age 80.
- 1. 20 to 25 indicates early AD
- 2. 10 to 19 indicates middle stage AD
- 3. Below 10 indicates late stage AD
Describe the management of AD?
The principle management of a D. are directed toward slowing progression of the disease, protecting physical health, providing emotional support and maintaining maximal possible function.
Treatment with cholinesterase inhibitors should be considered at the time of dx.
Aricept does not prevent progression of the disease, but it does affect the rate of decline.
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