N750 Exam 2 Study Guide Gal Pals PDF

- - Normal anatomy: - - - - - - - - - - - - - - - - - - - - - - - - - - From Class Slides: Chest & Lungs HPI: COUGH - - -...

- - Normal anatomy: - - - - - - - - - - - - - - - - - - - - - - - - - - From Class Slides: Chest & Lungs HPI: COUGH - - - - - - HPI: SHORTNESS OF BREATH (SOB) - - - - - HPI: WHEEZING - - - - REVIEW OF SYSTEMS (ROS) ENVIRONMENTAL & EXPOSURE HISTORY - - - PHYSICAL EXAM FOR RESP CONCERN **Purpose:** To detect abnormalities such as fluid, air, consolidation, or masses.​ **Goal:** Systematic assessment helps in diagnosing respiratory conditions early and guiding appropriate interventions.​ **Key Steps:**​ Inspection, Palpation, Percussion, Auscultation -  - - - - - - - Notes: AP Diameter: width of chest straight on and then on their side/lateral portion of chest; anterior should be 2x the lateral side ; AP usually 2:1; COPD will have barrel chest 1:1 ratio ​ Pectus excavatum: \"scooping out\" or hollowness of chest; \"bowl on chest wall\"​ Pectus carinatum: \"poking out\" have hump on the chest (pigeon chest)​ Respiratory distress: e.g. sternaclomastoid muscles being used accessory muscle use; if see these symptoms STOP & INTERVENE immediately before proceeding with rest of exam ​ ​Hyperpnea: abnormal e.g. metabolic acidosis; deeper breaths -- can occur w/ or wo inc. In RR​ Cheyne Strokes: cycle of increasing and decreasing breathing leading to temporary pause in breathing (apnea)​ Paradoxical breathing: chest wall moves inward w/ inhalation and outward w/ exhalation \[opposite of normal breathing\] - - - - - - - - - - - - - - - - - - Diaphragmatic Excursion - - Remainder of Slides was Case Studies Vocal Fremitus Article Notes​ -Tactile fremitus is palpation of chest wall to detect changes in the intensity of vibrations created with certain spoken words in a constant tone & voice indicating underlying lung pathology ​ -Pathophysiology: Transmission of spoken tones depends on state of underlying lung parenchyma in pleural space; air is a poor conductor of low sound frequencies whereas a solid or dense medium inc. Transmission of low sound frequencies. Vocal fremitus may be DECREASED in conditions affecting lung parenchyma, pleura, or chest wall. ​ Example: [Bronchial asthma, emphysema/COPD, or bronchial obstruction dt air trapping & dec. Density of lung parenchyma] ​ \--Pleural effusion & pneumothorax: air fluid accumulates in space between chest wall & lung parenchyma -\> dec. Transmission of lower frequency sound vibrations ​ \--Obesity: dec. Vocal fremitus ​ \--[Inflammation and consolidation create dense medium -\> INCREASED Vocal fremitus] w/ inc. Transmission of lower frequency sounds ​ -Vocal resonance is auscultatory counterpart of vocal fremitus; example changes in resonance: ​ \--Bronchophony: LOUDER sound over area of CONSOLIDATION ​ \--Whispering Pectoriloquy: While auscultate over lung fields, ask pt to whisper \"one, two, three\" \-- whispered words are HEARD CLEARLY in presence of CONSOLIDATION ​ \--Egophony or an \"E to A\" change: qualitative change in voice resembles \"bleating of a goat.\" Sound frequencies pass through consolidation tend to distort sound of vowel: \"E\" perceived by examiner as \"A\" or \"AAAH\" ​ -Rhonchal fremitus: palpable rhonchi ​ -Pleural fremitus: palpable pleural rub ​ **Examination for Tactile Fremitus:** ​ -Ask pt to fold arms across the chest wall to displace scapulae -- ask to repeat \"ninety-nine\" or \"one, two, three\" in constant tone while practitioner palpates chest wall on both sides using ulnar border of hand or palmar base. Palpation begins w lung apex and moves to same location on opposite side of chest wall ​ -Compare vibrations on both sides while moving hands from apex to base of the lung ​ -Repeat maneuver on anterior and lateral chest walls ​ ***Pneumothorax*** ​ Inspection: Diminished chest movements on the affected side. ​ Palpation: Diminished chest movements on palpation. Decreased vocal fremitus on the affected side. ​ Percussion: [Tympanic note] on percussion of the affected side. ​ Auscultation: Diminished breath sounds and vocal resonance on the affected side. ​ ​***Pleural effusion*** ​ Inspection: [Fullness of intercostal spaces] and diminished chest movements on the affected side. The apical impulse may not be visualized. ​ Palpation: Diminished chest movements on palpation of the affected side. Decreased vocal fremitus on the affected side. Trachea may be shifted to the opposite. The apical impulse may not be palpable. ​ Percussion: [Stony dullness] on percussion of the affected side. ​ Auscultation: Diminished breath sounds and vocal resonance on the affected side. Egophony may be present on the upper border of the effusion. ​ ***Consolidation*** ​ Inspection: Diminished chest movements on the affected side. ​ Palpation: [Diminished chest movements] on palpation of the affected side. Increased vocal fremitus on the affected side. ​ Percussion: Dullness on percussion of the affected side. ​ Auscultation: [Bronchial breathing sounds may be present.] [Increased vocal resonance] on the affected side may be associated with [bronchophony and whispering pectoriloquy. ​] ​[**Causes of increased vocal fremitus**: pneumonia, lung abscess, inflammation & consolidation] ​ ​[**Causes of decreased vocal fremitus**: pleural effusion, pneumothorax, emphysema/COPD, bronchial obstruction, bronchial asthma] ​ **Patient w/ Shortness of Breath Video**​ ​Scenario: Progressive SOB when walking reported by 65 year old Caucasian man approx 3 wks ago. Pt concerned about new onset of s/s. \"Im having difficulty breathing\"​ - - Patient reporting needing to stop halfway with stairs to catch their breath, no palpitations, chest tightness, syncope; no stents, bit of dry nonprod cough during night and day started 3 weeks as well; breathless at night laying In bed -- wake up \[paroxysmal nocturnal dyspnea\] needing to catch breath, put 2 pillows under head to raise it helps slightly; fullness in abdomen 3 weeks ago; swollen ankles (as day goes on) (new finding)​ Pertinent Positives: breathlessness at night, dry cough, dyspnea on exertion, peripheral edema​ - - - - - - - Physical Exam should include: General, Skin, HEENT, Resp, Cardiac, Peripheral vasc, GI​ ​HF s/s: S3 gallop, S3, JVD, Hepatomegaly, splenomegaly, Crackles (rales), wheezing peripheral edema, positive hepatojugular reflex​ - - Physical Respiratory Examination Components (From textbook) 1. Inspect the chest, front and back and sides, noting thoracic landmarks for: - - - - - 2. Evaluate Respirations for: - - 3. Inspect chest movement with breathing for symmetry and use of accessory muscles 4. Note any audible sounds with respiration (e.g. stridor or wheezes) 5. Palpate the chest for: - - - 6. Perform direct or indirect percussion on the chest, comparing sides for: - - 7. Auscultate the chest with the stethoscope diaphragm, from apex to base, comparing sides for: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - METABOLIC SYNDROME \-- Co-occurrence of metabolic risk factors for both T2DM & CVD: Abdominal obesity, hyperglycemia, dyslipidemia, and HTN DIABESITY: Diabetes & Obesity - - - - - - - - - - - - - - - - - - - \--DASH Diet Eating Plan \--Physical Activity Recommendations 4-9mmHg SBP Reduction with Aerobic Physical Activity​ for 30 minutes Most Days of the Week​ - - - - - \--Type 2 Diabetes (T2DM) Screening  ASCVD Risk Calculator: [[https://tools.acc.org/ASCVD-Risk-Estimator-Plus/\#!/calculate/estimate/]](https://tools.acc.org/ASCVD-Risk-Estimator-Plus/%23!/calculate/estimate/)​ - - - - USPSTF Statin Use Recommendations  - -  -  - Person-Centered / Culturally Effective Care \-- Respectful communication & building trust - - - - - - - - - OARS - - - - SDOH w/ Screening  LAB ARTICLES \-- WEEK 6 [CARDIOVASCULAR DISEASE AND RISK MANAGEMENT: STANDARDS OF MEDICAL CARE IN DIABETES---2021 \[Purple Highlighted Area Recommendations, Screening Recommendations & Primary/Secondary Prevention\]] - - - - - - - - - - - - -  - - - - - - - - - - - - - - - ASSESSING AND MANAGING THE METABOLIC SYNDROME IN CHILDREN AND ADULTS - - - - - - - - - - - - - - - The 5 *A*s framework for obesity management: Do we need a more intricate model?. *Canadian family physician Medecin de famille canadien* - - - Week 7 - HISTORY \[PPT\] - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ### Discuss the assessment of a patient for risk factors of cardiovascular disease - - - - - - - - - - - - - - - -   ASCVD RISK CALCULATOR PLUS LINK: [[https://tools.acc.org/ASCVD-Risk-Estimator-Plus/\#!/calculate/estimate/]](https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/) \\ HEART SCORE for Major Cardiac Events (Use in patients ≥21 years old presenting with symptoms suggestive of ACS. Do not use if new ST-segment elevation ≥1 mm or other new EKG changes, hypotension, life expectancy less than 1 year, or noncardiac medical/surgical/psychiatric illness determined by the provider to require admission.) [[https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-events]](https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-events) Risk Factors CVD \[PPT\] - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Causes of Secondary HTN - - - - - When to Suspect Secondary HTN? - - - - - ### Demonstrate knowledge of essential components of cardiac physical exam - Physical Examination Components: Heart (From textbook) The following steps are performed with the patient sitting, supine, and in the left lateral recumbent positions; these positions are all used to compare findings or enhance the assessment. Having the patient lean forward while in the seated position can bring the heart closer to the chest wall and accentuate findings. 1\. Inspect the precordium for: - - - 2\. Palpate the precordium to detect: - - 3\. Percuss to estimate the heart size (optional): 4\. Systematically auscultate in each of the five areas while the patient is breathing regularly and holding breath for: - - - - - - - 5\. Assess the characteristics of murmurs: - - - - - - - - - - [Common presenting symptoms for CV disease] - - - - - - [Palpitations]: irregular/ fluttering, rapid/ racing HR, skipped beats; may be w/ stress or exertion - - - - - [Dyspnea/SOB] - - - - - - - - [Peripheral Edema:] fluid in interstitial spaces, often in lower extremities - - - - - - - - [Syncope:] loss of consciousness (brief) - - - - - - - - - [Pleuritic Chest Pain] - - **Common Chest Pain Presentations** (from PPT) -- -- -- -- -- -- [Cardiac Physical Exam from Slides \[PPT\]: ] - PMI: Displaced PMI; normally at 5th intercostal space on left anterior chest - - Abdominal bruits - Extra heart Sounds: - S3: sign of LV failure- indicates high LV filling pressure and decreased LV compliance; heard best with patient in left lateral decubitus position - S4: during final phase of diastole when blood is ejected into non- complaint LV- HTN, elderly, aortic stenosis - Skin: color- pallor, jaundice - Neck: JVD, carotid bruits; diminished carotid pulsations, bounding carotid pulses - - Pulmonary: crackles, wheezes, diminished/ absent; labored - Abdomen: distended/ ascites, hepatomegaly, assess for RUG tenderness; bruits. HJR: hepatojugular reflex - Neuro: mental status - Extremities: - Pulses - Assess for bruits - Edema: volume overload, DVT, venous insufficiency - Muscle wasting - - Ulcers Heart Failure Functional Status Assessment - - - Common presenting s/s of CV disease \[PPT\] - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - [Changes w/ Aging] - - - - - - ### Discuss the most common diagnostic tests used in the evaluation of chest pain in the primary care setting. AHA Guideline Recommendations (From week 7 articles) for Setting Considerations-\> - - - - Presenting with Acute Chest pain: - - -  1. - - - 2. - - - 3. - - 4. - - 5. - - - - - - - - - - - - - - - - - 6. - - 7. - → Stress Testing Key Principles: - - - - - -  Differential Dx of Noncardiac Chest Pain  - ### Identify life-threatening causes of chest pain and appropriate need for referral - - - - - - - - - - - - - - - - - - - - - - Major adverse cardiac events (MACE)​ 0-3 points - low risk (6%) of event​ 7-10 points - moderate risk (50%) of an event ​ ST elevations and depressions -- call 911 [Patient w/ Acute Chest Pain Diagram - Workup ]  **Week 7 Articles** Acute chest pain in adults - - - - - - - - **[ACUTE CHEST PAIN ARTICLE ]** Here are the key points from this article on evaluating acute chest pain in adults in an outpatient setting: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - **[HEART FAILURE ARTICLE ]** The role of the clinical exam in the patient with HF The article \"The Role of the Clinical Examination in Patients with Heart Failure\" discusses the continued importance of the clinical examination (history and physical exam) in managing heart failure (HF), despite advances in biomarkers and technology. It emphasizes that clinical examinations allow noninvasive assessments of a patient's hemodynamic status, particularly focusing on ventricular filling pressures and cardiac output. This information is crucial for prognosis and guiding treatment decisions. Key points include: - - - - - - - - - - - - - - - - - - - - - - - - - - The article concludes that clinical exams are valuable, especially for assessing elevated ventricular filling pressures, though determining cardiac output remains challenging. Integrating biomarkers like natriuretic peptides with clinical exams can improve the diagnosis and treatment of HF. Heart Murmurs in children the article \"Heart Murmurs in Children: Evaluation and Management\" from *American Family Physician* (March 2022) focuses on the commonality of heart murmurs in children, highlighting the high lifetime incidence, with up to 80% of children experiencing them. The majority of these murmurs are innocent and not associated with heart disease, but distinguishing between innocent and pathologic murmurs remains a challenge for clinicians. Pediatric cardiologist referrals are common because of this difficulty. - - - - - - - - - - - - All infants should be screened for critical congenital heart disease using pulse oximetry, ideally 24 hours after birth. Key elements of evaluation include: - - - - Referral to pediatric cardiology is indicated for: - - - - - Echocardiography is not routinely needed for evaluation of innocent-sounding murmurs without other concerns. Routine use of ECG, chest x-ray, etc. is not cost-effective for evaluating murmurs without other signs of heart disease. Emerging technologies like phonocardiography and AI algorithms may aid in murmur evaluation in the future. Key points include: - - - - Overall, the article underscores the importance of clinical history, physical examination, and judicious use of technology in managing heart murmurs in children.   \*\*\*implications of pathological murmurs in children (table 6 in article has more information related to exam)  Week 8: Neurological 750 NEURO EXAM VIDEO NOTES: **[NORMAL SENSORY EXAM \-- POSITION SENSE (PROPRIOCEPTION) ]** - - **[MONOFILAMENT TESTING ]** [[https://www.youtube.com/watch?v=aQHDIkNSyxk]](https://www.youtube.com/watch?v=aQHDIkNSyxk)  - **[CLONUS]** - - - - **[ASTERIXIS (aka FLAPPING TREMOR)]**  - - - - - **[COVER/UNCOVER TEST]** - - - - - - - - - - - - - - - - - - - - - - - - **[ABNORMAL ROMBERG (ROMBERG TEST)]** - - - ASSESSING PERRLA: [[https://eyeguru.org/blog/examining-the-pupil/]](https://eyeguru.org/blog/examining-the-pupil/) - Method: While the patient looks at a distant target, shine the light from inferiorly and slightly temporal (shining the light from directly in front of the eye will stimulate the near reflex that will produce pupil constriction) - -  - Method: While the patient is looking at a distant target, shine the light on one pupil and notice the reaction in the other eye. - - - Method: Ask patient to focus on a distant object in a moderately lit room. Hold a Snellen chart about 30 cm in front of the patient's eyes. Instruct the patient to look at the Snellen chart. Observe for pupillary constriction, which may take up to 10 seconds in certain situations. Note: There is actually a triad of things occurring -- convergence of gaze, accommodation of the lens, and pupillary constriction. - Method: Use a bright handheld light in a dim room. Shine the light in one of the patient's eyes and observe for a reaction. After \~3 seconds, rapidly swing the light to the opposite pupil and observe the reaction. After \~3 seconds, swing back to the first eye and observe again. What is a "positive RAPD"? - - [5 Pupil Assessments: Size, Shape, Position, Color, Symmetry ]    [**Extraocular Movements (EOM) \--** utilize an "H" pattern for assessment] - **[HINTS exam for neuro]** **1. Head impulse test** -ask patient to stare at your nose -hold head, move it 30 degrees to the side and rapidly bring it to the midline -vestibular neuritis will show that eyes will move in direction of movement and quickly move back to looking at your nose (corrective saccade- only happens in one direction, be sure to test both sides) - peripheral cause of vertigo, reflex is not working \- if no corrective saccade, concern for central cause of vertigo, 8th CN not affected \- do not apply test to patients with episodic vertigo, are no longer symptomatic, or do not have nystagmus \- brain can compensate, perform test randomly to avoid a false negative result **2. Nystagmus evaluation** -ask patient to look slightly to the left and then to the right and look for slight changes in direction -look for bidirectional or vertical nystagmus as these point to a central cause of vertigo (stroke) -unidirectional nystagmus is reassuring **3. Test of skew** -have patient look at your nose -cover one eye and then move your hand quickly to cover the other eye -look for any vertical or diagonal movement as the eye is uncovered (trying to look at your nose) -abnormal vertical correction indicates central cause of vertigo Example: cerebellar stroke [Summary ] In a patient with acute persistent vertigo and nystagmus and a normal neurological exam a hints exam with a head impulse test showing a corrective saccade and with unidirectional nystagmus and no abnormal test of skew means that the patient has vestibular neuritis. If any of the three components of the hints exam are abnormal, the patient needs admission to the hospital. Test Central Origin Peripheral Origin ------------------- ------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- Head Impulse Test Normal test result - patient keeps visual focus w/ quick head movements Abnormal test result - pt loses focus w/ quick head movements indicating VOR is not intact Nystagmus Bidirectional or vertical None or unidirectional Test of Skew Abnormal correction (98% specific) Normal, no skew **[How to assess cranial nerves]** Cranial nerves - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - **NEURO EXAM IN 4 MINS VIDEO: [[https://www.youtube.com/watch?v=TTLrxlkDmms]](https://www.youtube.com/watch?v=TTLrxlkDmms)** ======================================================================================================================================== **Neurological Examination: Comprehensive Guide** ================================================= **Overview of Neurological Exam** --------------------------------- The neurological examination is a fundamental process for diagnosing and managing disorders affecting the nervous system. The exam focuses on localizing lesions, identifying signs of normal and abnormal neurological function, and guiding diagnostic and management decisions. **Key Objectives** ------------------ 1. - - 2. 3. - - - List four situations in which it would be necessary to perform a complete neurological exam A complete mental status exam (MSE) is typically necessary in the following situations: 1\. \*\*Initial Psychiatric Evaluation\*\*: When a person presents for the first time to a psychiatrist or mental health professional with symptoms of mental illness, an MSE is crucial for establishing a baseline understanding of their mental state. 2\. \*\*Change in Mental Status\*\*: If a patient experiences a sudden or unexplained change in behavior, thinking, mood, or cognitive function (e.g., disorientation, confusion), an MSE helps assess potential causes. 3\. \*\*Suspected Cognitive Impairment\*\*: In cases where there is concern about dementia, delirium, or other cognitive disorders (such as after head trauma or stroke), an MSE is necessary to evaluate memory, attention, language, and other cognitive functions. 4\. \*\*Emergency Settings\*\*: In psychiatric emergencies, such as when someone is suicidal, homicidal, severely agitated, or psychotic, a quick but thorough MSE helps guide immediate interventions and care decisions. 5\. \*\*Monitoring Mental Health Conditions\*\*: For individuals with chronic psychiatric disorders like schizophrenia, bipolar disorder, or depression, an MSE may be used periodically to track changes or treatment progress. 6\. \*\*Before Initiating or Changing Psychiatric Medications\*\*: When starting new psychiatric medications or adjusting dosages, an MSE helps establish a baseline to monitor for side effects or changes in mental function. 7\. \*\*Legal or Forensic Evaluations\*\*: In cases where someone\'s mental state is in question for legal reasons, such as in competency hearings, criminal responsibility assessments, or guardianship cases, an MSE is essential. 8\. \*\*Substance Use or Withdrawal\*\*: When substance abuse or withdrawal is suspected, an MSE helps assess the impact of substances on mood, cognition, and overall mental health. Each of these scenarios involves potential mental health challenges where a thorough assessment provides critical information for diagnosis, treatment planning, or crisis management. Which mental function is the 4 Unrelated Words Test intended to test? - **Goals of the Neurological History** ------------------------------------- - - - Review of History: PRESENT ILLNESS - - - - - PMH: - - - - - - - **Indications for Neurological Examination** -------------------------------------------- - - - **Components of the Neurological Exam** --------------------------------------- ### 1. Mental Status Testing - - - - - - - - -  ### 2. Cranial Nerve Examination **Cranial nerve assessment includes a review of all 12 nerves (CN I - XII) considering sensory, motor, and reflex functions.** #### **Testing Overview** - - - - - - - - - - - - - - - - - - - - - - - - - ### 3. Motor System Examination #### **Muscle Bulk, Tone, and Strength** - - #### **Motor Strength Testing** - - ### Motor System Testing - - - ### 4. Reflex Testing #### **Deep Tendon Reflexes (DTR)** - - - ### 5. Sensory Testing - - - - - - ### 6. Coordination and Gait Examination #### **Coordination Testing** - - - - - ### **Coordination** The cerebellum fine tunes motor activity and assists with balance. Dysfunction results in a loss of coordination and problems with gait. The left cerebellar hemisphere controls the left side of the body and vice versa. Specifics of Testing: There are several ways of testing cerebellar function. For the screening exam, using one modality will suffice. If an abnormality is suspected or identified, multiple tests should be done to determine whether the finding is durable. That is, if the abnormality on one test is truly due to cerebellar dysfunction, other tests should identify the same problem. Gait testing, an important part of the cerebellar exam, is discussed separately (see next section). 1. 1. 2. 3. 4. Interpretation: The patient should be able to do this at a reasonable rate of speed, trace a straight path, and hit the end points accurately. Missing the mark, known as dysmetria, may be indicative of disease. 2. 1. 2. Interpretation: The movement should be fluid and accurate. Inability to do this, known as dysdiadokinesia, may be indicative of cerebellar disease. 3. 1. 2. Interpretation: The movement should be performed with speed and accuracy. Inability to do this, known as dysdiadokinesia, may be indicative of cerebellar disease. 4. 1. 2. Interpretation: The movement should trace a straight line along the top of the shin and be done with reasonable speed.\ \ If the movement is accurate and smooth but slow, the likely problem is weakness. #### **Gait and Balance Testing** - - - **Specialized Tests: HINTS Exam** --------------------------------- Used to differentiate central from peripheral causes of acute vestibular syndrome (AVS). ### Head Impulse Test (HI-test) An assessment method that checks the vestibulo-ocular reflex by moving the patient\'s head and observing for corrective saccades. ### Nystagmus Observation Identification of spontaneous nystagmus and its direction by asking the patient to gaze left and right. ### Skew Deviation Test Checking for ocular misalignment by covering and uncovering one eye and observing for any corrective movements. **Diagnostic Linkage** ---------------------- ### Interpretation - - ### Clinical Conditions - - Week 8. Headache article The article is a comprehensive review of the diagnosis and management of headache disorders. It discusses the prevalence and classification of headache types, which are divided into primary and secondary headaches. **Primary headache disorders include migraines, tension-type headaches (TTH), trigeminal autonomic cephalalgias (TACs), and other less common types**. Secondary headaches are attributed to underlying medical conditions like vascular, infectious, or neoplastic causes. Key Points: 1\. [Primary Headaches:] Migraine is the most disabling and prevalent primary headache disorder, affecting 12% of people. It is treated with NSAIDs, triptans, gepants, and the newer 5-HT1F agonist lasmiditan. [Tension-type Headache (TTH)] affects 38% of the population and is managed with simple analgesics like acetaminophen and NSAIDs. [Trigeminal Autonomic Cephalalgias (TACs),] including cluster headaches, are rarer and present with unilateral pain and autonomic symptoms. 2\. Secondary Headaches: Secondary headaches are due to underlying issues and must be evaluated for possible urgent conditions such as cerebrovascular events or infections. 3\. Management: Acute treatment options include over-the-counter analgesics, triptans, and newer agents like gepants. Preventive treatments for migraines include antihypertensives, antidepressants, antiepileptics, botulinum toxin, and [monoclonal antibodies targeting the calcitonin gene--related peptide (CGRP).] 4\. Diagnostic Approach: Diagnosing headaches involves a thorough history and examination, focusing on distinguishing between primary and secondary causes. Diagnostic imaging or lumbar puncture is recommended in certain high-risk cases. 5\. Emerging Therapies: Neuromodulation devices and behavioral therapies are becoming increasingly recommended, particularly for patients with contraindications or who prefer nonpharmacological treatments. Diagnosis and management of headaches Articles \-- Focus on Diagnosis  752 Headache in Neurological Emergency Article Images - Week 7   [Common Problems Pediatric Neurology \-- Continuum \[Paroxysmal Non-Epileptic Disorders in Children and Epilepsy\]] Classification of Paroxysmal Non-Epileptiform disorders based on age of onset Differentiation between breath-holding spells and Epileptic seizures  Difference between stereotypies and tics Differentiation between non-epileptic seizures (pseudoseizures) & epileptic seizures  Neuron (UMN) Dysfunction v Lower Motor Neuron (LMN) Dysfunction \[CN 7\] [[https://meded.ucsd.edu/clinicalmed/neuro2.html]](https://meded.ucsd.edu/clinicalmed/neuro2.html) "The UMNs are part of the Central Nervous System (CNS), which is composed of neurons whose cell bodies are located in the brain or spinal cord. The LMNs are part of the Peripheral Nervous System (PNS), made up of motor and sensory neurons with cell bodies located outside of the brain and spinal cord. The axons of the PNS travel to and from the periphery, connecting the organs of action (e.g. muscles, sensory receptors) with the CNS." Babinski Response The Babinski response is a test used to assess upper motor neuron dysfunction and is performed as follows: 1. 2. 3. 4. 5. 6. Interpretation: In the normal patient, the first movement of the great toe should be downwards (i.e. plantar flexion). If there is an upper motor neuron injury (e.g. spinal cord injury, stroke), then the great toe will dorsiflex and the remainder of the other toes will fan out. A few additional things to remember:  Babinski Response Present 1. 2. 3. 4. 750 Week 8 Lab \-- Articles CURRENT CONCEPTS IN CONCUSSION INITIAL EVAL & MANAGEMENT - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Focused Neuro Exam for Suspected Concussion: Findings suggesting more severe injury +-----------------------------------+-----------------------------------+ | Assessment | Findings | +===================================+===================================+ | Balance† | Positive Romberg sign, postural | | | instability, unsteadiness | +-----------------------------------+-----------------------------------+ | Cranial nerves | Difficulties with vision, unequal | | | or fixed dilated pupils, abnormal | | | | | | extraocular movements, or other | | | abnormal cranial nerve | | | | | | findings may be suggestive of | | | brainstem lesion | +-----------------------------------+-----------------------------------+ | Deep tendon | Hyperreflexia or presence of | | | Babinski reflex suggest an upper | | reflexes | | | | motor neuron lesion | +-----------------------------------+-----------------------------------+ | Finger-to-nose test | Abnormal finding suggests | | | coordination deficit | +-----------------------------------+-----------------------------------+ | Gait | Ataxic gait may suggest | | | cerebellar dysfunction | +-----------------------------------+-----------------------------------+ | Mental status‡ | Prolonged loss of consciousness | | | (more than 30 minutes), | | | somnolence | | | | | | or confusion, disorientation or | | | posttraumatic amnesia | | | | | | for more than 24 hours, deficit | | | in language and speech | +-----------------------------------+-----------------------------------+ | Muscular strength | Weakness or unequal strength, | | | decreased tone; involuntary | | | | | | movements may indicate basal | | | ganglia or cerebellar injury | +-----------------------------------+-----------------------------------+ | Sensory assessment | Numbness or abnormal sensation | | | can be traced to spinal | | of dermatomes§ | | | | nerve root | +-----------------------------------+-----------------------------------+ | \*---Evidence is lacking as to | | | what a focused neurologic | | | examination should include. Most | | | | | | patients with a concussion have | | | cognitive and memory deficits; | | | therefore, any focal neurologic | | | | | | deficit should prompt immediate | | | further evaluation for possible | | | intracranial lesion. | | | | | | †---Standard balance examinations | | | are not sensitive to subtle | | | changes in concussion. Postural | | | | | | stability tests have low to | | | moderate sensitivity but strong | | | specificity for diagnosis (see | | | eTable A | | | | | | for examples of these tests). | | | | | | ‡---Standard orientation | | | questions are not sensitive to | | | subtle changes in concussion. | | | Maddocks | | | | | | questions (eTable A) are | | | sensitive and effective for | | | sideline use. | | | | | | §---Sensory examinations are | | | subjective and may be difficult | | | to perform on uncooperative | | | | | | patients or those with cognitive | | | deficits. | | +-----------------------------------+-----------------------------------+ Concussion Management - - - - - - - - - - - - - - - - -   LONG-TERM COMPLICATIONS OF STROKE AND SECONDARY PREVENTION: OVERVIEW - - - - - - - - - - - - - - - - - - - - - - - - - Neurological slides from class Importance of the neurological exam - - - Types of neurological localization - - - Goals of the neurologic history - - - - - - Indications for neurological examination - - - Key components of the neurological exam - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - WEEK 9 \-- MUSCULOSKELETAL (MSK) [[https://www.physio-pedia.com/Category:Special\_Tests]](https://www.physio-pedia.com/Category:Special_Tests) ← various tests that can be done for [each joint: wrist, elbow, hip, knee, ankle]. It will also tell you what the findings of the tests can indicate for you, making diagnosis, deciding what diagnostic tests need to be ordered, and management easier. - - MSK PHYSICAL EXAM & HISTORY \[Seidel Ch. 22 MSK\] Physical Exam Component: 1. - - - - 2. - - - - 3. - - - 4\. Palpate all bones, joints, and surrounding muscles for: - - - - - 6\. Test major muscle groups for strength and compare sides. Joints that deserve particular attention include the following: [Hands and Wrists] 1\. Inspect the dorsum and palm of hands for: - - - - 2\. Palpate each joint in the hand and wrist. 3\. Test range of motion by the following maneuvers: - - - - - - 4\. Test muscle strength by the following maneuvers: - - [Elbows] 1\. Inspect the elbows in flexed and extended positions for: - - 2\. Palpate the extensor surface of the ulna, olecranon process, and medial and lateral epicondyles of the humerus. 3\. Test range of motion by the following maneuvers: - - - [Shoulders] 1. 2. 3. - - - - 4\. Test muscle strength by the following maneuvers: - - - - [Temporomandibular Joint] 1. 2. - - - - [Cervical Spine] 1. 2. - - - - 3. [Thoracic and Lumbar Spine] 1. 2. 3. 4. [Hips] 1. 2. - - - 3. - - - - 4. - - [Legs and Knees] 1. 2. 3. 4. [Feet and Ankles]\ 1. Inspect the feet and ankles during weight bearing and non-weight bearing for: - - - - 2\. Palpate the Achilles tendon and each metatarsal joint. 3\. Test range of motion by the following maneuvers. - - - 4\. Test strength of muscles in plantar flexion and dorsiflexion. [HPI] [Joint Symptoms] - - - - - [Muscular Symptoms] - - - - [Skeletal Symptoms] - - [Injury] - - - - - [Back Pain] - - - - - [Past Medical History] - - - - [Family History] - - - - **[ARTICLE: RED FLAGS OF LOW BACK PAIN]** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - [ARTICLE: CONDUCTING OFFICE-BASED MSK EXAM] This article, titled \"Conducting an office-based musculoskeletal exam\" by Kristin Bird and Gerald Moore, provides a comprehensive overview of how to evaluate and diagnose common musculoskeletal complaints in a primary care setting. Here\'s a summary of the key points: 1\. Introduction: \- About one in seven patients seen by primary care physicians complains of musculoskeletal pain or dysfunction. \- It\'s crucial to determine whether symptoms are caused by local injury, inflammation, mechanical disorders, or systemic illness. 2\. Recognizing Life-Threatening Conditions: **- Physicians must immediately rule out serious conditions like trauma, compartment syndrome, and septic arthritis.** [COMPARTMENT SYNDROME] **6 P's: Pain, Pallor, Paresthesia, Paralysis, Pulselessness, Poikilothermia** \- **Red flags include red, hot joints, fractures, focal neurologic deficits, and constitutional symptoms.** 3\. Evaluation Process: \- Distinguish between true articular disease and soft tissue disorders. \- Assess active and passive range of motion. \- Evaluate pain characteristics, including location, quality, and alleviating/aggravating factors. \- Perform a complete physical examination and review of systems. 4\. Shoulder Disorders: \- Covers rotator cuff tendinitis, rotator cuff tears, bicipital tendinitis, adhesive capsulitis, osteoarthritis, and inflammatory arthritis. 5\. Elbow Disorders: \- Discusses lateral epicondylitis, medial epicondylitis, ulnar nerve entrapment, and olecranon bursitis. 6\. Wrist and Hand Disorders: \- Examines ganglia, De Quervain\'s tenosynovitis, radial nerve palsy, carpal tunnel syndrome, Dupuytren\'s contracture, trigger finger, and osteoarthritis of the first carpometacarpal joint. 7\. Disorders of the Spine: \- Covers back strain, lumbar disc herniation, osteoarthritis of the lumbosacral spine, and inflammatory back disease. The article provides detailed information on the physical examination techniques, diagnostic criteria, and treatment options for each condition. It emphasizes the importance of a systematic approach to musculoskeletal complaints and highlights the need to consider both localized and systemic causes of pain and dysfunction. [ARTICLE: DX & MANAGEMENT OF COMMON PEDIATRIC ORTHO DISORDERS] Here are key points summarized for each condition: **Clubfoot:** **Cavus (a high arch)** **Adduction of the forefoot (toes point medial or inward)** **Varus of the hindfoot (heel directed towards the midline) and** **Equinus (foot in plantar flexion)** \- Complex deformity characterized by cavus, adduction of forefoot, varus of hindfoot, and equinus \- Incidence around 1-2 per 1000 live births \- Can be idiopathic or associated with neuromuscular conditions/syndromes \- Diagnosed clinically, radiographs rarely needed \- Treatment is with the Ponseti method of serial casting and possible Achilles tenotomy \- After casting, patients wear foot abduction orthosis full-time for 3 months, then part-time until age 4 \- Recurrence is common (25-67% rate) and may require additional casting or surgery \- Referral to orthopedic specialist familiar with Ponseti method recommended Chronic pain is common complication **Developmental Dysplasia of the Hip (DDH):** \- Spectrum from mild acetabular dysplasia to complete hip dislocation \- Key risk factors are breech presentation and family history \- Screening done with physical exam (Ortolani/Barlow tests) in infancy \- Ultrasound screening recommended at 4-6 weeks for high-risk infants \- X-rays used for screening after 4-6 months of age \- Treatment depends on age and severity - may include Pavlik harness, closed reduction, or open reduction \- Goal is to maintain concentric hip reduction to allow normal development \- Referral to orthopedics needed for abnormal physical exam or imaging **Slipped Capital Femoral Epiphysis (SCFE):** \- Displacement of femoral metaphysis anteriorly/laterally on epiphysis \*Disorder the capital femoral epiphysis slips over the neck of the femur \- Typically occurs in adolescents, often obese \- Can present with hip, knee, or thigh pain \- Physical exam shows decreased internal rotation and abduction of hip; persistent hip pain \- Diagnosed with AP and frog-leg lateral x-rays of pelvis \- Treatment is urgent surgical fixation \- Complications include avascular necrosis and future arthritis \- Urgent referral to orthopedics or ED needed when suspected **Scoliosis:** \- Defined as spinal curve \>10° on x-ray; lateral curvature \- Most common type is adolescent idiopathic scoliosis \- Screening done with forward bend test and scoliometer \- X-rays indicated for scoliometer reading \>7° \- Curves 10-25° monitored, 25-40° often treated with bracing \- Curves \>50° usually require surgical fusion \- MRI indicated for atypical curves or early-onset scoliosis \- Referral to orthopedics recommended for curves \>20-25° [STANFORD LOW BACK EXAM: ] - - - - - - - - - - - - -  -   -  ORTHO VIDEOS Hoffman sign (tests for impingement): [[https://www.youtube.com/watch?v=GJ-Q2ibYAHs&t=2s]](https://www.youtube.com/watch?v=GJ-Q2ibYAHs&t=2s) - - Impingement sign: [[https://www.youtube.com/watch?v=TAgYnXnqmBc&t=2s]](https://www.youtube.com/watch?v=TAgYnXnqmBc&t=2s) - - - - Rotator cuff: [[https://www.youtube.com/watch?v=38AILl7Wvwk]](https://www.youtube.com/watch?v=38AILl7Wvwk) - - - - - - Thomas Test for hip flexion: [[https://www.youtube.com/watch?v=EocfXx18uFs]](https://www.youtube.com/watch?v=EocfXx18uFs) - - - - - - Milking effusion in the knee: [[https://www.youtube.com/watch?v=2R2BafJau24&t=6s]](https://www.youtube.com/watch?v=2R2BafJau24&t=6s) - - - Medial Collateral Ligament (MCL): [[https://www.youtube.com/watch?v=NVE1VtHc7JA]](https://www.youtube.com/watch?v=NVE1VtHc7JA) - - Lateral Collateral Ligament (MCL): [[https://www.youtube.com/watch?v=XgpGfNef-Sk]](https://www.youtube.com/watch?v=XgpGfNef-Sk) - - McMurray: [[https://www.youtube.com/watch?v=i3Znlg8lWD0&t=3s]](https://www.youtube.com/watch?v=i3Znlg8lWD0&t=3s) - - - - Lachman's: [[https://www.youtube.com/watch?v=HZ9C\_0a2qRI&t=1s]](https://www.youtube.com/watch?v=HZ9C_0a2qRI&t=1s) - - - Anterior Drawer: [[https://www.youtube.com/watch?v=HZ9C\_0a2qRI&t=1s]](https://www.youtube.com/watch?v=HZ9C_0a2qRI&t=1s) - - Posterior Drawer: [[https://www.youtube.com/watch?v=RSdFdiMMCk4]](https://www.youtube.com/watch?v=RSdFdiMMCk4) - - - - Class slides MSK - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ### Conditions Requiring Urgent Attention - - - - - - -