Neurology

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Chapter 35

• Neurology

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Introduction

• Nervous system is chief communication and command
  center for all parts of body
• Two divisions of nervous system
• Central nervous system (CNS) includes
• Brain
• Spinal cord
• Peripheral nervous system (PNS) contains
• Nerves that transmit impulses

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Common Nervous System Disorders

• Infectious disorders
• Degenerative disorders
• Seizure disorders
• Developmental disorders
• Trauma
• Brain tumors
• Headaches

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Infectious Disorders

• Meningitis
• Encephalitis
• Herpes zoster
• Poliomyelitis
• Tetanus
• Rabies
• Reyes syndrome

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Meningitis

• Inflammation of the meninges covering the spinal
  cord and brain
• Viral meningitis is usually not life-threatening
  and is often short-lived
• Bacterial meningitis is often severe and may be
  fatal

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Meningitis (continued)

• Symptoms
• Nausea
• Vomiting
• Fever
• Headaches
• Stiff neck
• Photophobia
• Rash

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Meningitis (continued)

• Treatment for viral meningitis
• Fluids
• Bed rest
• Treatment for bacterial meningitis
• Antibiotics
• Generally requires hospitalization

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Meningitis (continued)

• Medical assistants responsibilities
• Complete infectious diseases form
• Individuals (family, friends, coworkers) may
  require prophylactic treatment to prevent
  contracting disease

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Checkpoint Question 1

• How does the treatment of viral meningitis differ
  from that of bacterial meningitis?

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Answer

• Viral meningitis is treated with fluids and bed
  rest, and bacterial meningitis requires
  antibiotics and hospitalization.

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Encephalitis

• Inflammation of the brain
• Symptoms
• Drowsiness
• Headaches
• Fever
• Seizures and coma may occur in later stages
• Treatment
• Hospitalization for intravenous fluid therapy and
  supportive care
• Local health department should be notified

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Herpes Zoster (continued)

• Virus that spreads down length of a nerve causing
  redness, swelling, pain
• Treatment
• Analgesics or nerve blocks for pain
• Topically, calamine lotion may be applied to skin
  to reduce itching
• Antiviral medications

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Poliomyelitis

• Highly contagious virus that affects brain and
  spinal cord
• Symptoms
• Stiff neck, fever, headaches, and sore throat
• Nausea, vomiting, diarrhea
• Paralysis may develop
• Muscles atrophy

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Poliomyelitis (continued)

• Treatment
• Acute stage, palliative and supportive
• After acute stage, rehabilitation
• Emotional support

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Postppoliomyelitis Muscular Atrophy (PPMA)
Syndrome

• New dimension of disease documented in some
  individuals who had polio as children
• Symptoms
• Similar to those that signaled onset of original
  disease
• Treatment
• Outpatient basis with supportive care
• No cure available
• Emotional support

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Tetanus

• Infection of nervous tissue caused by
  Clostridium tetani
• All deep, dirty wounds should be treated as high
  risk for tetanus
• Symptoms
• Spasms of voluntary muscles
• Restlessness
• Stiff neck
• Seizures
• Dysphagia
• Facial and oral muscles contract

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Tetanus (continued)

• If untreated
• Respiratory muscles become paralyzed
• Disease typically fatal
• Prevention is best defense against tetanus
• Clean wounds immediately
• Remove dead tissue
• Antibiotics

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Checkpoint Question 2

• What are the initial signs of a tetanus infection?

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Answer

• The initial symptoms of a tetanus infection
  include spasms of the voluntary muscles,
  restlessness, and a stiff neck.

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Rabies

• Virus that spreads to the organs of central
  nervous system
• Animals that commonly transmit rabies
• Skunks Dogs
• Squirrels Cats
• Raccoons Coyotes
• Bats Foxes
• Initial symptoms
• Fever
• General malaise
• Body aches

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Rabies (continued)

• As disease progresses
• Mental derangement
• Paralysis
• Photophobia
• Drooling
• Immediate treatment of wound is first priority
• Antibiotics
• Prophylactic vaccine therapy
• All animal bites must be reported to animal
  control center

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Reyes Syndrome

• Nervous system illness typically occurs in
  children after viral illness
• Initial symptoms
• Vomiting
• Lethargy
• As brain swelling continues
• Confusion
• Seizures
• Coma

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Reyes Syndrome (continued)

• Treatment
• Rapid hospitalization
• Aggressive antibiotics
• Supportive care

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Degenerative Disorders

• Multiple sclerosis (MS)
• Amyotrophic lateral sclerosis (ALS)

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Multiple Sclerosis (MS)

• Myelin sheaths covering neurons
• Symptoms
• Progressive loss of muscle control
• Loss of balance
• Shaking tremors
• Poor muscle coordination
• Dysphasia
• Tingling and numbness

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Multiple Sclerosis (continued)

• As disease progresses
• Bladder dysfunction
• Visual disturbances
• Nystagmus
• Treatment
• Palliative
• Physical therapy
• Prosthetic appliances
• Muscle relaxants
• Steroids

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Amyotrophic Lateral Sclerosis (ALS)

• Terminal disease with no known cause that causes
  a progressive loss of motor neurons
• Begins with loss of muscle mobility
• Forearms
• Hands
• Legs

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Amyotrophic Lateral Sclerosis (continued)

• Progresses to
• Facial muscles
• Treatment
• Patient comfort measures
• Family education

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Seizure Disorders

• Seizures are involuntary contractions of
  voluntary muscles caused by a rapid succession of
  electrical impulses through the brain
• Seizures have many causes
• Epilepsy is most common form

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Seizure Disorders (continued)

• Petit mal seizures
• Usually occur only childhood
• Child may appear to fall asleep or drift away
  momentarily
• Some muscle twitching may occur
• Grand mal seizures
• Also called tonic-clonic seizures
• More involved than petit mal seizures

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Seizure Disorders (continued)

• Treatment
• During seizure, prevent injury to patient
• Epilepsy is treated with pharmacological agents
  that must be taken regularly

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Febrile Seizures

• Occur most commonly in children between the ages
  of 6 months and 3 years who are febrile
• Must have complete physical and neurologic
  examination to rule out organic origin
• Treatment
• Gently return childs body temperature to more
  manageable level
• Cool compresses
• Do not give aspirin products

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Focal (Jacksonian) Seizures

• Begins as small localized seizure that spreads to
  adjacent areas
• Cause of focal seizures must be researched to
  prevent progression to generalized seizures

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Checkpoint Question 3

• How do petit mal seizures differ from grand mal
  seizures?

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Answer

• Petit mal seizures are briefer in duration than
  grand mal seizures. Grand mal seizures are more
  extensive than petit mal seizures and have three
  phases an aura, or warning, of an impending
  seizure, complete loss of consciousness, and the
  postictal phase where the patient slowly regains
  consciousness.

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Developmental Disorders

• Neural tube defects
• Hydrocephalus
• Cerebral palsy

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Neural Tube Defects

• Abnormalities of the neural tube that occur
  during embryonic and fetal stages of development
• Developmental failure in proximal portion,
  anencephaly may result
• Abnormality in development in the distal end
  results in spina bifida

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Spina bifida

• Spina bifida occulta is most benign form
• Meningocele occurs when the meninges protrude
  through spina bifida
• Spina bifida with myelomeningocele
• Treatment
• Surgery

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Hydrocephalus

• Excessive cerebrospinal fluid present in
  arachnoid and ventricular spaces of brain
• Occurs more commonly in infants and children
• Sometimes occurs in adults as result of tumors or
  trauma
• Treatment
• Surgical insertion of a shunt

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Cerebral Palsy

• Group of neuromuscular disorders that result from
  CNS damage sustained during the prenatal,
  neonatal, or postnatal periods
• Impairment ranges from slight motor dysfunction
  to catastrophic physical and mental disabilities
• Treatment is supportive and rehabilitative
• Currently, no cure exists

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Trauma

• Traumatic injuries are most common causes of
  neurological disorders
• Trauma often occurs as result of preventable
  injuries
• To help prevent these injuries
• Encourage parents to require helmets for their
  children
• Bike riding
• Skateboarding
• Encourage all patients to wear seat belts in
  motor vehicles

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Traumatic Brain Injuries

• Pediatric population is particularly at risk for
  head trauma
• Head is large in proportion to rest of body
• They often fall head first
• Reflex systems are immature
• Traumatic injuries include
• Concussions
• Contusions
• Intracranial hemorrhages

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Concussions

• Nonlethal brain injury that results from blunt
  trauma
• Patient may experience momentary loss of
  consciousness but returns to an awake and alert
  state promptly
• Treatment involves rest and observations for
  signs of more serious injury

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Contusion

• Involves a focal alteration of cerebral
  circulation
• Hemorrhages and extravasation of blood and fluid
  can result
• Loss of consciousness
• Brain damage may occur
• Patient may become confused, lethargic, and have
  nausea and vomiting

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Intracranial hemorrhages

• Bleeding of a vessel inside skull due to
• Trauma
• Congenital abnormalities
• Aneurysms

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Intracranial hemorrhages(continued)

• Treatment for contusions and hemorrhages
• Surgery
• Drug therapy
• Supportive care
• Prognosis for all brain injuries
• Depends on extent of damage and location of injury

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Spinal Cord Injuries

• Complete spinal cord injury
• Cord is transected
• No neurologic abilities remain below point of
  injury
• Incomplete spinal cord injury
• Cord is injured or partially severed
• Minor to severe neurologic disabilities below
  point of injury

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Spinal Cord Injuries (continued)

• Treatment
• Initial consideration is to prevent further
  damage
• Treatment in emergency department focuses on
  stabilization
• Patients usually require extended hospitalization
  and rehabilitation

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Spinal Cord Injuries (continued)

• In physicians office, patients
• May receive follow-up treatment and evaluation
• Be monitored for changes in their reflexes
• Be evaluated for physical and occupation therapy

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Checkpoint Question 4

• How does a complete spinal cord injury differ
  from an incomplete one?

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Answer

• A complete spinal cord injury involves total
  transaction of the spinal cord with no neurologic
  abilities remaining below the point of injury. An
  incomplete spinal cord injury is one in which the
  cord is spared, with minor to severe neurologic
  disabilities below the point of injury.

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Brain Tumors

• May be either malignant or benign, many occur as
  metastatic sites
• Symptoms
• Vague complaints of headaches
• Blurred vision
• Personality changes
• Memory loss

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Brain Tumors (continued)

• More advanced cases
• Seizures
• Blindness
• Dysphagia
• Treatment
• Surgery
• Radiation therapy
• Chemotherapy

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Headaches

• 70 of population experiences eephalgia, or
  headaches
• May have variety of origins including
• Trauma
• Bone pathology
• Infections
• Vascular disturbances
• In many instances
• Etiology will never be known

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Migraine Headaches

• One of the most common types of headaches
• Symptoms
• Preceded by an aura
• Unilateral temporal headache
• Photophobia
• Diplopia
• Nausea

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Migraine Headaches (continued)

• Treatment
• Analgesics
• Rest in a dark, quiet room
• Medications to stop headache when migraine begins

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Other Common Headaches

• Tension headaches
• Contraction of muscles of neck and scalp due to
  stress
• Treatment involves muscle relaxants, analgesics,
  and reversing precipitating factors
• Cluster headaches
• Similar to migraine headaches
• Typically occur at night
• Treatment requires muscle relaxants, analgesics,
  and stress relief techniques

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Common Diagnostic Tests for Disorders of the
Nervous System

• Physical examination
• Radiologic tests
• Electrical tests
• Lumbar puncture

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Physical Examination

• Key component in diagnosing nervous system
  disorders
• Mental status and orientation
• Cranial nerve assessment
• Sensory and motor functions
• Reflex assessment

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Radiologic Tests

• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI)
• CT or MRI with contrast medium or dye
• Myelogram
• Cerebral angiogram
• Radiography of skull

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Electrical Tests

• Electroencephalogram (EEG)
• Noninvasive test
• Records electrical impulses in brain
• Variety of electrodes placed on patients scalp
• Tracings of brain wave activity are recorded
• Patient typically given mild sedative to induce
  quiet state
• Used to assess hyperactive electrical responses
  in brain as seen in patients with seizure
  disorders

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Checkpoint Question 5

• What are the differences between a myelogram and
  an EEG?

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Answer

• An EEG is a noninvasive, electrical test of brain
  waves. A myelogram is an invasive, radiologic
  test in which dye is injected into the CSF to
  help detect abnormalities.

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Lumbar Puncture

• Procedure used to diagnose infectious,
  inflammatory, or bleeding disorders affecting the
  brain and spinal cord or as a means of injecting
  medications for pain control into the spinal
  column

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Lumbar Puncture (continued)

• Needle is inserted into subarachnoid space at
  level of L-4 to L-5, below the level of the
  spinal cord
• CSF is removed and sent to laboratory to be
  tested for
• Glucose
• Protein
• Bacteria
• Cell counts
• Presence of red blood cells indicating
  intracranial bleeding
• Evaluate intracranial pressure

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Lumbar Puncture (continued)

• Queckenstedt test
• Used to determine presence of an obstruction in
  the CSF flow
• Medical assistant presses against patients
  jugular veins in the neck while physician
  monitors pressure of CSF

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Lumbar Puncture (continued)

• If lumbar puncture is performed in medical
  office, medical assistant will
• Assist patient into a side-lying, curled position
  or a supported, forward-bending sitting position
• Maintain sterility of items used during puncture
• Help patient to relax by encouraging slow, deep
  breathing