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Transcript: Neurology By Sam Waltimyer A neurologist is a medical doctor or osteopath who has trained in the diagnosis and treatment of nervous system disorders, including diseases of the brain, spinal cord, nerves and muscles Neurologist Education Requirements Four years of premedical education in a college or university Four years of medical school resulting in an MD or DO degree (doctor of medicine or doctor of osteopathy degree) One year internship in either internal medicine or medicine/surgery At least 3 years of specialty training in an accredited neurology residency program Licensure and board examinations to be able to work in hospitals. Neuroscience is the scientific study of the nervous system. Traditionally, neuroscience has been seen as a branch of biology. However, it is currently an interdisciplinary science that works with other fields such as chemistry,computer science, engineering, linguistics, mathematics, medicine and allied disciplines, philosophy, physics, and psychology. The term neurobiology is usually used interchangeably with the term neuroscience, although the former refers specifically to the biology of the nervous system, whereas the latter refers to the entire science of the nervous system. Neurologists work in hospitals, public or private clinics, and universities or research facilities. Many neurologists are in private practice. Neurologists new to the profession make around $150,000 per year. The average salary for a neurologist is $208,000. However, neurolgists that have developed a good name can make around $300,000. As most other physicians do, neurologists are not able to follow a 40-hour workweek. The job can be quite stressful, and treating patients properly may require working for more than 60 hours in a week. Neurologists employed in busy medical facilities may have to put in extra hours during the week and also work on weekends. Those who work in research facilities and medical schools, however, enjoy regular working hours. Job prospects for neurologists are expected to be very good in the coming years. As the baby-boomer generation approaches older age, rate of occurrence of neurological problems, like dementia and stroke, is expected to rise considerably, creating good job opportunities for neurologists. Got Nerve? Works Cited

Neurology for finals

Transcript: On inspection: facies and resting tremor? Ask the patient to walk: gait Ask the patient to stand still ? postural instability? Ask the patient to sit: rigidity? synkinesia and bradykinesia Afferent - CN II Efferent - CN III parasympathetic If testing left pupil Direct reflex tests CN II and CN III on Left Consensual reflex tests CN II on Right and CN III on Left anterior horn, root, peripheral nerve The examination Common Motor to trapezius and sternocleidomastoid - Cannot turn head towards affected side Differentials CN III palsy (peripheral nerve lesion) Horner's syndrome (symphathetic lesion) MG (NMJ lesion) Rapid side-to-side movement is cerebellar Diabetes, EtOH, GBS, entrapment Rarer Peripheral neuropathy Parkinson's Disease Upper Motor Neuron Brain Brain stem Spinal cord Lower Motor Neuron Peripheral nerves Some branches of CNs Types of seizure LMN sign - wasting Know how to examine: UL and LL Cranial Nerves including eye movements For cerebellar signs Parkinsonian Patient Gait Speech For brain stem reflexes CN II - Optic Examining the cranial nerves Anterograde. Dermatomal - rarer LMN Central palsy - pseudobulbar (hot potato) Peripheral - bulbar Subarachnoid Haemorrhage Epilepsy Muscles of facial expression Sensation to anterior 2/3 tongue UMN lesion e.g. stroke - lower (opposite) side of face affected only as bilaterally innervated LMN lesion e.g. Bell's palsy - ipsilateral forehead involved NB: Herpes Zoster Oticus - Ramsay Hunt syndrome with involvement of vestibulocochlear nerve D: Dysdiadochokinesia A: Ataxia N: Nystagmus I: Intention tremor S: Slurred speech H: Hypotonia V: Vertigo T: Titubation Stroke and TIA Horner's Syndrome X - efferent gag reflex, palatal elevation, vocal cords, parasympathetic supply 1. History - Onset - seconds, minutes, hours, days, weeks - Progression - ?intermittent, time course 2. Examination - Central (brain and cord) versus - Peripheral (anterior horn, peripheral nerve, NMJ, muscle) LMN - wasted, floppy Partial seizures (begin focally) Simple (consciousness not affected) - motor (frontal, Jacksonian March), sensory (parietal), psychological deja vu (temporal) Complex (consciousness impaired) but usually no loss of postural control. Automatisms, altered emotion, strange tastes or sensations, usually last 10-15 minutes Partial seizure may become generalised Absence: 4-12 y/o, eye blinking jerks, school performance Myoclonic Tonic-clonic seizures: tonic: elbows flexed, legs extended, cyanosis. clonic: 1-2 minutes, tongue biting, tachycardia, loss of continence. Post ictal phase NB Todd's Paresis - transient paresis following seizure. May affect eye movement, motor system. Usually lateralises to one side. Occurs in 10-15% of all seizures. Important differential is obviously a CVA Red flags: Progressive Sudden Age > 50 Worse in morning Associated neurological deficit Tension type: analgesic overuse Migraine: in women, episodic, unilateral, aura, fortification spectra, exacerbated by movement Cluster headache: in men, pain around the eye, conjunctival injection, lacrimation, severe enough to wake from sleep Temporal arteritis: in elderly, raised ESR jaw claudication and scalp tenderness MG, Lambert Eaton Myasthenic Syndrome LMN Blood supply Sensation to face Corneal reflex Jaw jerk (UMN) Median nerve e.g. carpal tunnel: abductor pollicis brevis weakness Ulnar nerve e.g. interosseus weakness Midbrain III, IV Pons V, VI, VII, VIII Medulla IX, X, XI, XII V1 Opthalmic - sensory V2 Maxillary - sensory, autonomic V3 Mandibular - motor, sensory, proprioceptive, parasympathetic Cranial Nerves Reflexes may help localise the lesion: Biceps (C5,6) Triceps (C7,8) Knee (L3,4) Ankle (S1) (cc) image by anemoneprojectors on Flickr Loss of Consciousness To complete... ask the patient to write (micrographia), do a BP (SD), DHx, Slit lamp (Wilson's) decreased CN - VII Facial UMN Clinical Anatomy Cord syndromes Spinal Cord brain, brainstem, cord absent XII - Hypoglossal Muscle pathology Tone Brain (unilateral and hemi-body, higher cognitive symptoms) Basal ganglia (movement, PD) Brain stem (CN symptoms, reflexes, autonomic functions) Cerebellum (ataxia, nystagmus) Spinal cord (sensory level, legs >arms) Anterior horn (UMN and LMN) Peripheral nerve (glove stocking, single nerve) NMJ (fatiguable) Autonomic (diarrhoea, sweating) NMJ Blue: Anterior Pink : Middle Green : Posterior NB. spinal shock DMD, Inflammatory causes Cavernous Sinus Vertebrobasilar ischaemia UMN Meningitis CN III, IV, VI Hypotensive XI - Accessory contracture Pupillary light reflexes Central cord e.g. syringomyelia - rare. Differential sensory loss - spares dorsal columns. UL LMN signs LL UMN signs Pituitary tumour at chiasm - bitemporal hemianopia Lesion in optic radiation - homonymous hemianopia or quadrantanopia (lower=patietal, upper=temporal) Reduction of C02 --> cerebral vasconstriction Light headedness Perioral anaesthesia Carpopedal spasm Anxiety, fatigue Rarely causes complete LOC Inspection Cord compression is a

Neurology for finals

Transcript: Aetiology - - neurodegenerative disease, characterised by: - Loss of dopaminergic neurons from substantia nigra and formation of lewy bodies. Normal SN - promotes appropriate movements. Abnormal SN - unable to promote movement resulting in - - Tremor - Bradykinesia - rigidity Management 1. muscular skeletal - pretty much always most common - 2. lots of other 'medical causes' - drugs, endocrine, electrolyte, rheumatological, genetic, metabolic, od (sarcoidosis, amyloidosis) 3. Neuro - good stuff - vascular - stroke - inflammatory - MS - trauma - bleed, compression, spinal - autoimmune - - metabolic - B12 deficiency - infectious - polio, tetanus, botulism etc - Neoplastic - intracerebral, spinal - degenerative - MND, Mysathenia, Case 3 - Epilepsy - Syncope - Cardiac syncope / drop attack - arrythmias, stokes adams - Vasovagal syncope - including reflex anoxic seizure - NEAD/ pseudoseizure As with everything in neuro - tend to have good idea from clinical picture however to confrim Imaging - gadolinium MRI - you get gadolinium enhancing lesions - classically periventricular - demyelination and spinal cord (transverse myelitis) Neurophysiology delayed visual evoked potentials and other evoked potentials CSF electrophoresis oligoclonal bands of IgG in CSF not present in the serum demonstrate 2 lesions - so clincally weakness then neurophysiology shows previous optic neuritis etc. NON-MEDICAL - PT - increase strength, balance, posture etc - OT - maximise patients funtionality - Social services - assess home circumstances - Dietician - SALT MEDICAL Acute phase - corticosteroids! - methylprednisolone can only use couple of times a year - shortens symptoms duration but not relapse rate Chronically now lots of things... but the common things are beta interferon / Interferon 1B natalizumab - monoclonal antibody to the VLA-4 receptor prevents white cells crossing BBB prevent demyelination SE?? PVL? JC virus.. bone marrow transplant? SURGICAL - NA 1. relapsing remitting 2. secondary progressive 3. primary progressive 4. progressive relapsing anxiety and depression constipation urinary incontinence/ dysfunction pain weight loss/gain dementia - lewy body - sexual dysfunction orthostatic hypotension REM behavior disorder restless leg syndrome 32 Year old lady returns from holiday in Spain. Whilst away she has noticed difficulty swimming and weakness in her left leg. When reviewing her notes you noticed she missed an ophthalmology appointment that the GP made, as she feels she now has no problems with her eyes. 1. What are your differentials? 2. important questions to ask in a history of weakness? Investigations Medications - 1st line: dopamine agonist - ropinirole, pramipexole -2nd line: - COMT - entacapone - MAO-B - Resagaline -3rd line - Levo Dopa +PDI - Co-careldopa +/- amantidine Side effects: on symptoms - tics and dystonia off symptoms - freezing and severe parkinsoism Surgery - Deep brain stimulation - subthalamic nucleus and the globus palidus Loss of Consciousness MS!! - multiple sclerosis! autoimmune, demylinating disorder targeting any neuron myelinated by an oligodendrocyte - brain, spinal cord and the optic nerve. destruction of myelin sheath Loose the ability to jump from node to node via saltatory conduction - severe slow down nerve conduction - leading to symptoms eventually remyelinate - but myelin is not as good - relapsing remitting pattern over time cant remyelinate - secondary progressive. Epidemiology – women> men 3:1 Occurs more commonly in temperate regions. Rarer in black african/asian Typical age of onset – 30 years Take away messages 2 neurological symptoms, separated in space and time Clinical diagnosis! - It is all in the history - most dont need investigating. Epilepsy - EEG - Sleep study - sleep deprevation, flashing lights, telemetry etc. - Neuroimaging - temporal sclerosis, hypocampal lesions. New seizure >50 years - CANCER - cortical localisation - young people focal seizures. Syncope - ECG - Echo - tilt table test NEAD - psych input, counceling, adress psychosocial issues, stress, anxiety, depression etc. - very challenging to treat. Unilateral Optic Neuritis - visual loss, colour desaturation, pain on movement. Motor - weakness Sensory - pins and needles/ sensory loss Lhetmittes phenomenon Utoffs phenomenon Cerebellar symptoms - ACRONYM Any neurological symtpom- UMN NMO? severe form of MS Differentials Exciting Stuff!!! Management - Partial – carbamazipine - Complex – sodium valproate - Pregnant – lamotrigine valproate is teratogenic. - Vagal nerve stimulation – reduce incidence of seizures – doesn’t stop them completely - Surgery – temporal lobeectomy – temporal lobe epilepsy. Notify the DVLA – cant drive until seizure free for 1 year, and HGV – never drive again – so be careful when diagnosing! Swimming, and risky activities! Neurodegrenerative disease Clinically Xander Beer Management History - have a system and stick to it. Investigations - start simple and build to more complex

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