CAUSE AND EFFECT

structural or metabolic

Processes producing coma

focal lesions of the ARAS (tegmental pons, midbrain)

Will cause profound alterations in consciousness

extensive, bilateral, diffuse hemispheric lesions

Can cause unconsciousness

lesions in the thalami or hypothalamus

Can cause unconsciousness

head trauma

Should be asked about in a comatose patient's history

seizure disorder

Should be asked about in a comatose patient's history

recent change in mood, behavior, thinking, or neurologic condition

Should be asked about in a comatose patient's history

Insulin/diabetes mellitus or alcohol use

Should be asked about in a comatose patient's history regarding coma causes

access to depressant medications or street drugs

Should be asked about in a comatose patient's history regarding coma causes

allergies, insect bites, and other causes of anaphylactic shock

Should be asked about in a comatose patient's history regarding coma causes

checking pupillary size and reactions

Is part of the eye examination in a patient with altered consciousness

examining optic fundi

Is part of the eye examination in a patient with altered consciousness

assessing position and movement of the eyes spontaneously and in response to the vestibulo-ocular reflex

Is part of the eye examination in a patient with altered consciousness

touching a cotton swab to the outer edge of the iris

Is one method for checking the corneal reflex

unilateral flaccid paralysis of buccinator and other facial muscles

Will cause flaccid cheek that sucks in with inspiration and puffs out with expiration on the affected side

limb-dropping tests

Demonstrate flaccid paralysis of the extremities

applying deep pressure to areas like the condyles at the TMJ or supraorbital notches

Is a method to test response to noxious stimuli

response to auditory stimuli (including voice)

Is assessed as part of mental status examination in patients with altered consciousness

oculocephalic (doll's eyes) reflex testing

Is part of the cranial nerves examination in patients with altered consciousness

vestibulo-ocular (caloric testing) reflex testing

Is part of the cranial nerves examination in patients with altered consciousness

a rise of CO2

Stimulates the medullary respiratory centers, triggering the apnea test

choroid plexuses of the lateral, III and IV ventricles

Form CSF

CSF in ventricles and subarachnoid spaces

Provides a flotation layer around the brain and spinal cord, cushioning them from trauma

altered consciousness, seizures, or suspected elevated ICP in a patient with new onset neurologic signs/symptoms

May warrant an MRI or CT scan before a lumbar puncture

a compressive spinal cord lesion

May warrant an MRI before a lumbar puncture

a patient in the lateral recumbent position with head, spine, and extremities flexed (fetal position)

Increases the distance between dorsal processes and lamina of adjacent vertebrae for lumbar puncture

spikes or sharp waves that occur interictally (epileptiform discharges)

Are abnormal EEG patterns seen in Epilepsy

intracranial mass lesions

Are associated with focal/localized slow-wave activity (usually delta) or occasionally seizure activity on EEG

Herpes simplex encephalitis

May show high-voltage sharp waves and slow-wave complexes at intervals of 1-3/sec in the temporal region on EEG

Alzheimer disease

May show diffuse slow wave abnormality in the theta (4-7 Hz) range on EEG

Creutzfeldt-Jakob disease

May show periodic bursts of high-amplitude sharp waves, usually bisynchronous and symmetrical on EEG

EMG machines

Are needed to determine the CMAP area (area above the baseline to the negative peak)

a Somatosensory Evoked Potential (SSEP) study

Assess the sensory pathways

an SSEP latency 2.5 or 3 standard deviations above the mean

Is considered abnormal

asking the patient to close their eyes during sensory testing

Helps avoid visual cues

comparing homologous areas of the right and left sides and normal areas to suspected abnormal areas during sensory testing

Is a general screening pattern

applying a non-vibrating tuning fork after a vibrating one during vibration sense testing

Tests patient reliability

applying the metal shaft of a tuning fork or a finger

Can be used to test temperature sensation

applying a straight pin with its sharp and dull ends

Can be used to test pain sensation

a dermatomal map

Is essential for localization of the level of lesion in the spinal cord

irritation of the subarachnoid space

Is the most common cause of nuchal rigidity

head flexion

Will cause stretching of the spinal cord

testing for nuchal rigidity via head flexion

May elicit a positive Brudzinski sign (leg adduction and flexion)

flexion of the neck

Places tension on the entire cord and roots

flexion of the legs

Reduces stretch on nerve roots

keeping the knee flexed and flexing the limb at the hip with the patient supine

Is part of the Kernig sign test

a reduction in SBP ≥ 20 or DBP ≥ 10 within 3 minutes of standing or head-up tilt table testing

Meets the criteria for orthostatic hypotension

clenching teeth and interlocking fingers together (Jendrassik maneuver)

Can increase excitability of reflexes

stroking the lateral side of the sole with the sharp point of a tongue blade or wooden end of a cotton-tip applicator

Elicits the plantar reflex

great toe dorsiflexion and fanning of other toes in response to plantar stimulation (Babinski sign)

Is an abnormal plantar response

observing the patient when they walk in the clinic or when they are naked

Is part of the general inspection in a motor examination

asymmetry, malalignment, fasciculations, tremors, and involuntary movements

Are checked for during general inspection in a motor examination

proximal weakness

Is usually how muscle diseases present

distal weakness

Is usually how nerve diseases present

velocity dependent increased resistance with faster stretch

Describes spasticity

constant resistance independent of velocity

Describes rigidity

resistance equal in degree and range in any direction

Describes paratonia

dementia or inability to relax completely

Are associated conditions with paratonia

knowing the onset, conditions that trigger/alleviate, relation to sleep/emotion, pattern, distribution, rate, amplitude, and force

Helps describe involuntary movements

anatomic organization

Lends the nervous system to a fine analysis of localization

localization (anatomic diagnosis) and time course (etiologic diagnosis)

Can help formulate an initial differential diagnosis

migraine, trauma, vascular lesions, or metabolic derangements

Are examples of conditions with hyperacute onset

infectious and inflammatory conditions

Are examples of conditions with acute onset

tumors or degenerative neoplasm

Are examples of conditions with chronic onset

identifying the affected site in the nervous system

Is part of formulating a clinical diagnosis

recognizing impaired function

Is often the main part of formulating a clinical diagnosis

patient's medical history

Provides the most important information for reaching the correct neurologic diagnosis

the chief complaint

Is the start of problem-finding in neurology

asking specific questions to distinguish possible causes

Helps in developing a hypothesis about possible etiologies

listening to the patient describe the problem in their own words

Can help appease patient worries

reviewing systems like Head, Neck, Lungs, Heart, Abdomen

Is part of the Review of Systems

symptoms patients may not spontaneously volunteer

Are intended to be elicited by the Review of Systems

dysuria unrelated to the chief complaint of headache

Would typically be included in the Review of Systems

polyuria in a patient with headache and blurring vision

Could serve as a clue to a co-existing condition like diabetes mellitus

Diabetes Mellitus, Hypertension, Heart disease, Lung disease, Tuberculosis, Thyroid disorders, Cancer, Stroke, Migraine

Are conditions to review in the Past Medical History

avoiding leading questions like "May sakit ka po ba?"

Is a trick of the trade in history taking

offering a selection of adjectives like "tumitibok, hinihiwa, pinupukpok, sumasabog"

Can help a patient describe the quality of their headache pain

a more bizarre and unusual symptom

Is more likely to be organic (brain pathology)

Spending more time listening to patients

Is associated with doctors who did not receive litigation

reflex hammer, tuning fork (128/256 Hz), pen light, cotton, tongue depressor, opaque containers with coffee/sugar/salt, stethoscope, ophthalmoscope

Are basic tools for the neuro examination

fatigability

Is the hallmark of neuromuscular junction lesions

proximal symmetric weakness without sensory loss

Is characteristic of muscle lesions

Multifocal distribution

Is typical in conditions like multiple sclerosis or metastatic tumors

Assessing levels of sensorium and using the Glasgow Coma Scale

Are clinical examination methods for consciousness

Eye Opening, Verbal Response, Motor Response

Are the components of the Glasgow Coma Scale

Glasgow Coma Scale scoring

Has limitations that can be compensated for with descriptions of a patient's activities that reflect their mental state

Glasgow Coma Scale Motor Response grade M2

Is characterized by extension to pain

Glasgow Coma Scale Motor Response grade M3

Is characterized by abnormal flexion to pain (decorticate)

Glasgow Coma Scale Motor Response grade M5

Is characterized by localizing to painful stimulus

lesions in the upper midbrain or upper pons

May result in decorticate or decerebrate posturing

assessing general behavior and appearance, stream of talk, mood and affect, content of thought, intellectual capacity, and sensorium

Are components of the Mental Status Examination

the Ascending Reticular Activating System (ARAS)

Is the neural structure for consciousness and attention span

medial temporal lobes, hippocampal fornix-mamillary body circuit, basal forebrain

Are neural structures for recent memory and orientation

the Left angular gyrus

Is the neural structure for calculation

the Frontal lobes

Are the neural structures for insight, judgment, and planning

reciting months backwards or spelling "WORLD" backwards

Tests attention

asking about current activities, events, or news

Tests fund of information

asking situational questions

Tests insight, judgment, and planning (part of executive function)

asking a patient to interpret a proverb

Tests abstract thinking

contralateral parietal lobe lesion

Can cause inability to identify an object by touch (astereognosis)