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CVA cerebrovascular accidant - History taking and OSCE
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CVA cerebrovascular accidant - History taking and OSCE

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note about CVA , very intersting and very useful for student and doctors …

note about CVA , very intersting and very useful for student and doctors
contain proper way to compose and take very nice history and guidance to dignosis

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  • Complete weakness within 48hours

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  • 1. بسم الله الرحمن الرحيم CVA Academic group OF internal medicine - Revision note of CVA- 2010 Dr. Mohamed Eisam Elhag Mahmoud MBBS, Alneelain University Faculty of Medicine Note: Dr. Mohammed Isam Al-Hajj does not have any financial relationships to disclose nor will he discuss any non-approved drug or device uses.
  • 2. # Personal History:
    • -name
    • -age : usually in elderlly but there is some cases in young!!
    • Q-causes of CVA in young?
    • A.V.M
    • CVS disease => embolism , A.F , post MI
    • Premature atherosclerosis
    • Arterial Disection
  • 3.
    • Therombophilia
    • Antiphospholipid “anticardiolipin syndrome”
    • Vasculitis , SLE
    • Bleeding disordor
    • Berry aneursm
  • 4.
    • -sex. – residance . –tribe . –occupation . – marital state
    • * Pt. is Rt. / or Left handed => “ dominant hemisphere”
    • - D.O.A:- pt. admitted at twinty second of / /2010.
    • # C/O: Rt. Side weakness , which preceded by numbness.
  • 5. #HPI:- “ pridiposing Factors must mention at first ”
    • If the => pt. is known case of:-
    • 1- HTN for 5 yr , recived captopril&not on regular ttt.
    • 2- DM for 7 yrs ,on oral hypoglycemic agent but not on regular medication.
    • 3- Mitral stenosis for 4 yrs, not recived digoxine.
  • 6.
    • The condition started 1 day P.T.A by weakness which is:-
    • Onset:
    • Sudden -> Embolism “with maximum intensity at the begin”
    • Rapid-> Therombosis”pt.weak up from sleep then after few hours develop weakness “
    • Drammatic-> Haemorrhage “when pt. do his ordinary activity”
  • 7.
    • Gradual -> SOL “focal lesion then>>>-progress”
    • Intermittent -> multiple sclerosis “ scatterd in place ,time & disease . may in young , ex. Pt. blind >>>then monoplegia.
    • Trauma !!
  • 8.
    • 2- The condition ass ot ass with Coma => cortical lesion
    • 3- The weakness ass ot ass with sign of incrase IC P =>SOL “headach, convulsion , loss of consciousness”
    • 4- The weakness ass ot ass with Fever & Convulsion => absccess & granuloma
    • 5- The weakness ass ot ass with Sphintric disturbance => anterior cerebral artery.
  • 9.
    • 6- The weakness ass ot ass with Cranial nerves disturbance “ especially 7 th => mouth devation”
    • -7 th C.N palsy + weakness at same side -> un-crossed hemiplegia “ at level of cerebral cortex”
    • - 7 th C.N palsy + weakness at opposite side=> crossed hemiplegia” at the level of Brain stem”
  • 10. 7- The weakness ass ot ass with Speech disturbance => cortical lesion.
    • Aphasia
    • Sensory: can talk but can not understand.=fluent=receptive, ask him to follow your command?ex. touch your right ear with left hand?
    • Motor: can understand but can not talk.= nonfluent=expressive. Ask him to till you the pen parts? ( most common “Brocas aphasia”
    • Global: sensory + motor
  • 11.
    • Dysphasia => cortex
    • Dysartheria => internal capsule , Brain stem , may cerebllum, basal ganglia, Tongue ex. Aphthous ulcer. ( slurred,staccato,scanning)
    • Dysphonia: volume of speech=> vocal cord:- innervation, candida,papilloma.
  • 12.
    • THEN , complete the CNS analysis:-
    • - SENSORY => no/ there parathesia , numbness,….
    • - remaining of cranial nerves:
    • Normal smelling, no visual disturbance, no double vision , no affection of eyes movment, difficult in mastication,affect of face sensation, jaw hang, deviation of mouth, accumulation of food ,loss of hearing, balance disturbanc , change in voice, difficult in swalowing, no diffecult in speech, can rise his shoulder, rotate his neck.
  • 13.
    • Degree of disability: cant walk, walk with asscistance.
    • Cerebellar sign
  • 14. # systemic review:
    • CVS: valvular lesion => shooting embolus. (no chest pain , no palpatation “imp. Negative”). MI->shooting thrombus.
    • RS: TB => tubercloma act as SOL.
    • GIT: espcially Diarrhea -> dhydation->>thrombotic state.
    • Renal : polycystic kidney->ass e sacular aneyrsum->may rupture “ Haemorrage”
    • Skin: any skin rash or Bleeding=>bleeding tendancy “haeg.”
    • Gynoclogical: menarch,menopause , amount => increase bleeding tendancy.
  • 15. # PMH:-
    • T.I.A : transient neurological deficit”ischemic”, with complete recovery within 24h.
    • R.I.N.D : reversible ischemic neurological deficit”=>recovery from 24h---7days.
    • Simillar condition. *causes of recurrent stroke? Multiple sclerosis, CVS disease not treated well,bleeding tendancy.
    • No DM , no HTN
    • TB, syphilis => act as SOL.
    • Hospitilization & blood tranfusion-> (HIV,Toxoplasma,1ry CNS lymphoma).
  • 16.
    • #FH: DM, HTN, simillar condition->PKD, familial hyperlipidemia, bleeding tendancy.
    • #Drug history:
    • Not known to be sensitive to any medication known to him/her including pencillin.
    • On regular medication: oral contraceptive=> increase viscosity of blood->> thrombotic.
    • Antiplatelet ,anticoagulant,NSAID,steroid .
  • 17.
    • # social history: housing condition , educational level,jop,health insurance, sibling =>(to know who is take care of pt.) ,bad habites->smooking,alcoholic. Classes(low/modrate/high)socioeconomic class.
  • 18.
    • #summery:- 68yr old male , known case of HTN for 5 yrs not on regular medication, present with Rt. Side weakness, the condition ass with aphasia & loss of consciousness.
  • 19. O/E:
    • General: looks ill, lay flat, average wt.& height , not tachypnic or orthopnic, has NG-tube in his Rt. Nostril, canulated in Rt. Hand
    • Vital signs: BP , PR ,RR , Temp.
  • 20. Neurologically:
    • Oriented in t ime, p lace & p erson
    • Memory for remote ,recent&immediate events are intact.
    • In good mood , good bhaivours & intelligent.
    • He suffer from motor aphasia
  • 21. Cranial nerves examination ……..
    • Motor System:-
    • Posture
    • Abnormal movment
    • Trophic change
    • Wasting
  • 22. Motor examination
    • Inspection
    • Tone
    • Power
    • Reflexes
    • Coordination
  • 23.
    • Tone:
    • Hypertonia “spastic” 1may be+clonus, if hypotonia=>spinal shock.
    • - Power :
    • determin grade of power.
    • examine each group” weakest”,
    • - Reflexes:
    • deep-> tendon.
    • Superficial-> planter reflex , abdominal reflex.
  • 24.
    • # Sensory:- according to dermatome
    • 1-Superficial: touch, pin prick
    • 2- Deep : vibration, position sense.
    • 3- Cortical sensation: asterogenosis , tow points discrimination , sensory intention, apraxia,graphesia.
    • if there any disturbance=>
    • Coordination
    • Gait : circumduction
    • Back examination.
  • 25.  
  • 26.
    • Then Examine:
    • CVS: for irregular irregular pulse-> Atrial fibrillation
    • Pericardium ->underling valvular lesion.
    • Carotid pulse& carotid bruit.
    • Eyes: DM retinopathy, HTN retinopathy, Arcus senile.
    • Examine other systems.
  • 27. Q- How to investigate this pt?
    • CT-scan : immediately done to role out haemorage, but infarction will visualize up to 12 h.
    • MRI: gold stander investigation
    • Carotid Doppler: to show stenosis , if there + pt.=> for Endoarterectomy.
    • Investigation for underling causes:
    • Blood sugar, cholesterol level , Hb ,
    • ECG, Echo. ,
    • ANA , Anti-DNA , Anti-thrombin III , Protein C & S , Urine.
  • 28. Q- what are the risk factors for stroke?
    • 1- Non – modifiable:
    • Age, gender “m>f “ , hereditary , previous vascular events(MI – stroke – peripheral embolism).
    • 2- Modifiable:
    • HTN , cigarette smoking , DM , Hyperlipidemia , HF , AF , alcoholic , + FH , oral pill , & polycythamia.
  • 29. Q- What is your dignosis?
    • CVA, Rt. Side hemiplegia due to left cortical lesion which result of Embolism from cardiac source “mitral stenosis complicated by atrial fibrillation “ associated with Rt. UMN Fascial Nerve palsy “ uncrossed hemiplegia” , pt. has motor aphasia, now pt. is improved slightly .
  • 30. Q- where is the site of lesion?
    • A- Cortical:
    • Convulsion
    • Coma => impair consciousness
    • Un-crossed hemiplegia -> power different
    • Homenumus hemnopia
    • Aphasia => if lesion affect dominant hemisphere
    • Absence of cortical sensation.
  • 31.
    • B- Internal capsule:
    • Deep hemiplegia
    • Deviation of mouth “uncrossed”
    • Dysphagia -> risk aspiration pneumonia
    • UMN Fascial palsy –same side
    • No convulsion, No coma, No aphasia, No hemnumous heminopia.
  • 32.
    • C- Brain stem:
    • Symptoms
    • (4D)=> Dysartheria,Dysphonia, Diplopia&Dysphagia. “ipsilateral C.N dysfunction”. 3 RD C.N palsy, impair upgaze.
    • Fascial palsy usually LMN
    • C rossed :
    • Contralateral spastic hemiparesis
    • Hyperreflexia & extensor plantar response (UMN).
    • Contralateral hemisensory loss & ipsilateral incoordination.
  • 33. Q- what is the nature of lesion? Haemorrage Infraction embolism thrombosis Dramatic onset Occure when pt in his/her ordinary activity Sudden onset with max. intensity at the begin Rapid onset when pt. weak up from sleep then within hours weakness at maximum onset. Also condition associated with: Vomiting Convulsion fever Usually there is clear source of embolism. Ex. . cardiac -> preceded palpitation . Fat embolism ” bone fracture” . air embolism . pulmo. Embolism -> VSD “paradoxical embolism” Source: . HF . MI
  • 34. Q- What is the complications of stroke?
    • 1- Chest infection. 2-Dhydration.
    • 3- hyponatremia. 4-hypoxemia. 5- seizures.
    • 6- DVT & pulmonary embolism.
    • 7-Frozen shoulder. 8-Bed sore.
    • 9-urinary infection. 10- constipation.
    • 11- psychological harmfull.
    •  
  • 35. Q- How to manage such pt.?
    • General :
    • Psychological support
    • Frequent change position to prevent bed sore.
    • NG- Tube
    • Urinary catheterization.
    • Physiotherapy-> to prevent wasting & contraction.
    • Specific: for underling cause
  • 36.
    • Q- what are the poor prognostic factors of CVA?
    • Elderly 2- co-morbid disease 3-re-infraction 4-haemorage inside infraction 5- coma 6-hypoxemia 7-hypercapnia 8-itrogenic->rapid decrease of high BP.
  • 37.
    • Q- mention extracranial sites of thromboembolism?
    • 1-carotid &its branches 70% . 2- heart 20% (AF) 3-5%different
    •  
    • Q- mention risk factors for haemorragic stroke?
    • HTN, AVM , Bleeding disorders, &anticoagulant ttt.
  • 38. Q- What is Door needle time mean in treatment of stroke?
    • If the pt. present within 1 st 3 hour “befor cytotoxic oedema formation” We can give Thrombolysis after exclude haemorrage & We can give Asprin safty, the best thrombolytic is => t.PA ( S/E: increase haemorrage size)
    • If the source of thrombosis:
    • Inside heart=> warferin
    • Outside heart=> asprin 300mg crushed immediately, Endartrectomy => if carotid 70% occluded.
  • 39.
    • Q- if the lesion?
    • In middle cerebral artery:- Weakness in arm & face > leg.
    • In Anterior cerebral artery:- Weakness in leg > arm & face.
    • Q- what is the prognosis of TIA? ( ROLE OF 30%)
    • 30% will develop nothing
    • 30% will develop TIA within 2 years
    • 30% will develop TIA within 6 month& 30% of them will die
    •  
  • 40. Thank you for your attention Now start of OSCE…..
  • 41. www.smso.net Best whishes أليس الماضي و عبق التاريخ يا رمز النضال لؤلؤة النيل حورية الضفاف باهية الجمال هواك يناديني فأهرع عبر المدائن و البوادي و التلال
  • 42.  
  • 43.  
  • 44. BRAIN ABSCESS
  • 45. EPIDURAL HEMATOMA
  • 46. SUBDURAL HEMATOMA
  • 47.
    • ASSESS GRADES OF BEST MOTOR RESPONSE (Max score 6)
    • 6 Carrying out request ('obeying command')
    • 5 Localizing response to pain.
    • 4 Withdrawal to pain - pulls limb away from painful stimulus.
    • 3 Flexor response to pain - pressure on nail bed causes abnormal flexion of limbs
    • 2 Extensor posturing to pain - stimulus causes limb extension
    • 1 No response to pain.
    The Glasgow coma scale (GCS)
  • 48.
    •   ASSESS GRADES OF BEST VERBAL RESPONSE (Max score 5)
    • 5 Oriented - patient knows who & where they are, and why, and the year, season & month.
    • 4 Confused conversation - patient responds in conversational manner, with some disorientation and confusion.
    • 3 Inappropriate speech - random or exclamatory speech, no conversational exchange.
    • 2 Incomprehensible speech - no words uttered, only moaning.
    • 1 No verbal response.
    •  
    Cont
  • 49.
    • EYE OPENING (Max score 4)
    • 4 Spontaneous eye opening.
    • 3 Eye opening in response to speech - that is, any speech or shout.
    • 2 Eye opening in response to pain.
    • 1 No eye opening.
    • TOTAL SCORE ...... / 15 RECORD YOUR FINDINGS You may record you findings on a specific ‘CNS’ chart. Otherwise record in the following fashion:  
    Conti
  • 50.  
  • 51.  
  • 52. UMN Vs LMN
    • UMN – contralateral facial weakness with forehead sparing
    • LMN – ipsilateral facial weakness with no forehead sparing
  • 53. Bell’s Palsy
    • Acute LMN nerve palsy
    • Unilateral
    • Inflamed facial nerve within petrous temporal bone
    • 24 hx ear ache
    • No sensory loss
    • Idiopathic
    • ?HSV – acyclovir – inconclusive evidence
    • ?short course high dose steroids
    Worth learning a differential for facial weakness: Acoustic neuroma Bell’s Palsy Middle ear infection Ramsay-Hunt syndrome Parotid gland tumours Mumps Guillain-Barre Mononeuritis multiplex MS MND
  • 54. What is this Condition? Ramsay Hunt Syndrome
  • 55. Cerebellar Examination
    • Coordination
    • Intention Tremor
    • Finger nose test
    • Gait
    • Heel Knee Test
    • Dysdiadokokinesis
    • Nystagmus
  • 56. Power Grading (Medical Research Council Scale)
    • 0 No movement
    • Flicker of movement
    • Movement but not against gravity
    • Movement against gravity but not resistance
    • Weak movement against resistance
    • Normal
  • 57. Upper motor neuron lesion
    • Stroke (hemiplegia), cerebral palsy, MS (spastic paraplegia)
    • No muscle wasting
    • Pyramidal weakness
    • Upper limb – weak abductors and extensors (flexed)
    • Lower limb – weak adductors and flexors (extension)
    • Increases tone (spasticity/ clasp knife)
    • Hyperreflexia and clonus. Upgoing plantar.
    • Circumductive gait
  • 58. Peripheral neuropathy
    • Usually generalised (diabetic), mononeuropathy (medicn nerve) or radiculopathy
    • Distal sensory or motor and sensory loss
    • Inspection - Pes cavus, wasting, fasciculation,clawing
    • Tone – decreased
    • Power – distal weakness
    • Reflexes – Reduced/ absent
    • Sensory – glove and stocking loss / paraesthesia
    • Disease affecting pathology of the peripheral nerves may be perfectly normal/ proximal weakness (Guillain- Barre syndrome)
    • Eg Charcot- Marie-Tooth,
  • 59.  
  • 60.  
  • 61. Retina Optic Nerve LGB Optic radiation Chiasma Lower fibres (Temp lobe) Upper fibres (ant parietal lobe) Occipital Cortex
  • 62. Retina Optic Nerve LGB Optic radiation Chiasma Lower fibres (Temp lobe) Upper fibres (ant parietal lobe) Occipital Cortex
  • 63. Retina Optic Nerve LGB Optic radiation Chiasma Lower fibres (Temp lobe) Upper fibres (ant parietal lobe) Occipital Cortex
  • 64. CN II:
  • 65. Optic Nerve Lateral Geniculate Body Pretectal Nucleus Edinger – Westphal Nucleus of III Convergence Centre Cilliary Ganglion Cilliary Body - Iris Afferent Pathway Efferent Pathway
  • 66.  
  • 67. Extra Ocular Eye Muscles
  • 68.  
  • 69. Signs of right third nerve palsy
    • Ptosis, mydriasis and cycloplegia
    • Abduction in primary position
    • Limited depression
    • Limited adduction
    • Normal abduction
    • Limited elevation
    • Intorsion on attempted
    • downgaze
  • 70.  
  • 71. Important causes of isolated third nerve palsy Idiopathic - about 25% Vascular disease - hypertension, diabetes Posterior communicating aneurysm Trauma Extradural haematoma Prolapsing temporal lobe Edge of tentorium Aneurysm Chiasm Third nerve Posterior cerebral artery Midbrain pushed across
  • 72. Horner’s Syndrome
    • Ptosis
    • Miosis
    • Anhydrosis
    • Enopthalmos
    • Lesion to cervical/sympathetic chain
    • EXAMS: Horner’s syndrome = pancoast tumour
    • BUT ptosis does not = horner’s
    • Could be CN III lesion
  • 73. Anatomy of fourth nerve
    • Only cranial nerve to emerge dorsally
    • Crossed cranial nerve
    • Very long and slender
    Internal carotid artery Postr. communicating artery III VI Postr.cerebral artery Supr.cerebellar artery Basilar artery IV
  • 74. Signs of right fourth nerve palsy
    • Right overaction on left gaze
    • Right underaction on depression
    • in adduction
    • Vertical diplopia
    • Right hyperdeviation in primary
    • position when left eye fixating
    • Excyclotorsion
    slightly upwards and outwards (extorsion)
  • 75. Recent right sixth nerve palsy Right esotropia in primary position due to unopposed action of right medial rectus Marked limitation of right abduction due to right lateral rectus weakness
  • 76. Hess chart of recent right sixth nerve palsy
    • Contraction of right chart and expansion of left
    • Right chart - marked underaction of lateral rectus and mild overaction of medial rectus
    • Left chart - marked overaction of medial rectus
  • 77. Left VI Nerve Palsy (lateral Rectus)
  • 78. CN V: Trigeminal Nerve
    • Sensory
      • Patient eyes closed
      • Cotton wool
      • Touch each division left and right
      • Compare each side
      • Corneal reflex – not normally done!
    • Motor
      • Ask patient to clench teeth
        • Temporalis
        • masseter
    • Jaw jerk
      • Not normally done!
      • Checking for UMN lesion (brisk reflex)
  • 79.  
  • 80. CN VIII: Vestibulo-cochlear
    • “ noticed any change in hearing?”
    • Hearing:
      • Block other ear
      • Rubbing fingers together, see when they can no longer hear it
    • Rinne’s – tuning fork louder in front or behind?
    • Weber’s – is it louder in one ear?
  • 81.  
  • 82. CN IX: Glossopharyngeal
    • Sensory: post 1/3 rd of tongue (facial nerve ant 2/3 rd )
    • Motor: stylopharyngeus
    • Autonomic: salivary glands
    • Inspect:
      • Position of uvula
    • “ say aahh”
      • See if the uvula deviates to one side (away from abnormal side)
  • 83. CN XI: Accessory Nerve
    • Inspect neck:
      • Sternomastoid wasting/fasciculation
      • Shoulders equal?
    • Put you hand on side of face and say “push against my hand”
    • Test each shoulder separately:
      • Shrug your shoulder against my hand”
    • UMN: ipsilateral sternomastoid and contralateral trapezius wasting
    • LMN: ipsilateral sternomastoid and trapezius wasting
  • 84.  
  • 85. CN XII: Hypoglossal Nerve
    • Inspect tongue (resting inside mouth)
      • Wasting, fasciculations
    • Stick your tongue out:
      • Watch if is deviates to one side:
        • Weakness on the side it deviates to
  • 86.
    • Representative of Case History #2
    • Guillain-Barré Syndrome (GBS)
    • acute inflammatory demyelinating polyneuropathy
    • disorder of the peripheral nerves
    • attack of the myelin sheath of nerves by antibodies or white blood cells
    • rapid onset of ascending paralysis
    • begins with weakness and/or abnormal sensations of the legs and arms
    • breathing muscles may be so weakened
    • following gastrointestinal or respiratory viral infections
    • palpitations (sensation of feeling heartbeat), difficulty beginning to urinate, incomplete bladder emptying, incontinence (leaking of urine), constipation, and muscle contractions
  • 87. Representative of Case History #1 DUCHENNES MUSCULAR DYSTROPHY Gower’s Sign
    • marked enlargement of calves
    • hyperlordosois
    • decreased tendon reflexes
    • normal sensation
  • 88. The end…..
    • Thank You!!
    Be the change ,which you want to see in the World