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Role of duty doctors in neurology emergency care class DR Ganesh.pptx
- 1. DR GANESHGOUDA MAJIGOUDRA CONSULTANT NEUROLOGIST NANJAPPA HOSPITALS DAVANAGERE ganeshgoudam4@gmail.com 9380906082 ROLE OF DUTY DOCTORS IN NEUROLOGICAL DISORDERS
- 2. INTRODUCTION • Name • Age • Sex • Handedness • Resident of • Education • Occupation • Informant • Reliability
- 3. STROKE PATIENT • 1) HISTORY- • Onset of symptoms- Time...............Date............ • Activity at stroke onset – • Wake up stroke- • Time of presentation to Emergency - • Symptoms- onset & course • (a) Headache –(b) Vomiting (c) Loss of conscious(d) Seizures (e) Weakness (f) Side(g) Aphasia(h) Facial paresis (i) Visual disturbances(j) Dysphagia • (k) Dysarthia (l) Ataxia (m)Vertigo / tinnitus
- 4. STROKE PATIENT 2) RISK FACTOR ASSESMENT- • 1) Hypertension – • 2) Diabetes – • 3) Dyslipidemia- • 4) Smoking- • 5) Alcohol intake- • 6) Atrial fibbrillation- • 7) RHD or CAD • 9) Obesity • 10) H/O TIA or stroke-
- 5. HEADACHE • Onset, • Duration • Severity – VAS Score • Site ,frequency, • Aggreviating factor • Releiving factors • Associated symptoms • Photophobia,phonophobia, nausea, vomiting • Double vision, slurred speech, swallowing difficulty, walking imbalance SNOOP4 (“snoop for” red flags)
- 6. NECK AND BACK ACHE • Onset, duration, site, severity • Injury ,weight lift • Past surgery • Radiating or localized • Aggravating or relieving factors • Coughing sneezing straining will worsen ? • Numbness/weakness of limbs, urinary disturbances • Fever, weight loss, HIV, steroid intake, older age ,
- 7. SEIZURES • Age of onset, duration • birth insult, growth developmental delay • Any premonitory symptoms • Urinary, stool incontinence , tongue bite, Rolling up of eyes/stare/grunting noise /abnormal breathing pattern • Tonic, clonic or nay jerky movements • Limb onset • Loss of consciousness and duration • Family history, current drug dose and compliance • Previous investigations • Past history of trama, enchephelitis, stroke
- 8. LOSS OF CONSCIOUSNESS • Onset, Activity at the time of incident • Preceded by • Chest pain/Palpitation sweating/nausea/ vomiting/ • headache/giddiness/pre syncope/visual disturbance. • Lasted for (Duration), Recovered after – Spontaneous/treatment • Any injury sustained. • Fever, headache, vomiting , limb weakness, speech disturbances, vertigo • Syncope history/seizure history /stroke history/CAD/CKD/liver failure • Alcohol/drug consumption/toxins • Chronic malnutrition/systemic complaints/psychiatric disorders
- 9. SPEECH DISTURBANCE • Onset • Comprehension • Any spontaneous speech/word outflow • Slurring • Reading/writing/repetition • Progression • Any stress during speaking • Tightness/looseness in tongue • New words/ un understandable words •
- 12. HISTORY AND EXAMINATION Quality of dizziness Vertigo or clear spinning Vestibular mechanism Near faintness Cardiovascular/ hemodynamic mechanism Other descriptions Mechanism less clear Timing and duration Brief recurrent spells (1 min) BPPV Others - vascular, cardiac, psychological Recurrent spells of dizziness (1 to 15 minute) Vertebrobasilar TIA, vestibular migraine, panic attacks Recurrent dizziness (hours) Vestibular migraine or Meniere disease (fluctuating hearing) Chronic ongoing dizziness (continuously for weeks) Anxiety or Vestibular migraine Other causes - recovering vestibular neuritis or brainstem/cerebellar lesions or drug toxicity
- 13. HISTORY AND EXAMINATION Triggering circumstances Specific head movement BPPV Worsened by head movement Vestibular mechanism - central or peripheral Exclusively on standing or walking ( not in recumbent) Hemodynamic mechanisms Others - simple gait unsteadiness Tullio phenomenon/sound Superior canal dehiscence syndrome Optokinetic motion sickness Vestibular mechanism
- 14. HISTORY AND EXAMINATION Associated symptoms Unilateral hearing loss with spinning vertigo Labyrinthine disorders Diplopia, dysarthria, or focal weakness or numbness with vertigo CNS vestibular mechanism Nausea Characteristic of vestibular (central / peripheral) Nystagmus Spontaneous direction-fixed Peripheral vestibular mechanism Spontaneous vertical or horizontal gaze evoked nystagmus CNS
- 15. NEGATIVE HISTORY • Injury/RTA/Trauma to the neck • Abnormal behavior/nausea/vomiting • Fever/chest pain/palpitations/cough/dyspnea/hemoptysis • Bowel symptoms/Jaundice • Oliguria/dysuria/hematuria/high colored urine • Joint pain/rash/photosensitivity/oral ulcers/hair fall/seizures • Dog bite/animal bite/vaccination/injection • Alternative drugs/well water drinking/insecticides /exposure • Carrying weight in head for long/neck pain for long • skin lesions/Nodules • Hypo/hyper thyroidism symptoms • Blood transfusion
- 16. PAST HISTORY • 1. DM/TB/HTN/CAD/BA • 2. Similar illness in the past • 3. Animal bite/vaccination/injection in the past • 4. Blood transfusion/jaundice • 5. Major surgery • 6.Drugs history/duration/dose
- 17. PERSONAL HISTORY • 1. Veg/Non veg/Well water drinking/food habits • 2. Smoking/Tobacco/Alcohol/Substance abuse • 3. Marriage/Children • 4. High Risk behavior
- 18. MENSTRUAL HISTORY • 1. Menarche/Cycles/Menopause • 2. LMP/Post menopausal bleed • 3. Any surgery
- 19. OCCUPATIONAL HISTORY • 1. Nature/duration/intensity of exposure • 2. H/O exposure to dye/paint/glass wares/med eqpts/jewellery • 3. Plumbing/farming/insecticides • 4. Vibrating eqpts/repeated trauma
- 20. OTHER • FAMILY HISTORY • 1. Pedigree charting of possible genetic disease • 2. H/O similar illness in the family TREATMENT HISTORY
- 21. GENERAL EXAMINATION • 1. Consciousness/orientation/cooperative • 2. Ht/Wt/BMI • 3. Pulse-Rate/rhythm/volume/ All peripheral pulse /Delay/pulse deficit/vessel wall/carotid bruit/shudder • 4. BP mm Hg/Rt Arm supine/No significant postural fall • 5. RR – rate/rhythm/type • 6. P/I/C/C/L/E/JVP •
- 23. SYSTEMIC EXAMINATION • 1. CVS • a. Apical Impulse/chest wall symmetry/anomalies • b. S1/S2/S3/S4/murmur/pericardial rub/knock 2. RS • a. Chest wall symmetry • b. Air entry/Breath sounds/adventitious sounds/pleural rub 3. P/A • a. Distended/all quadrants moves equally with the respiration • b. Soft/Non tender/organomegaly/free fluid/bowel sounds • c. Hernial sites/peripheral signs of liver failure
- 24. CNS EXAMINATION • 1. HMF • a. consciousness • b. oriented to T/P/P c. Language-Speech /Comprehension/Spontaneous speed/slurred speech
- 25. CRANIAL NERVES • Vision/ pupils reaction to light • Position of the eye at primary gaze • Extra ocular movements • Facial sensations touch/pain/temp/vibration/facial deviation on pain • Uvular position • Gag reflex
- 26. MOTOR SYSTEM EXAMINATION • a. Position/attitude of limbs • b. Bulk (wasting/hypertrophy) • c. Tone • d. Power
- 27. MOTOR SYSTEM EXAMINATION REFLEXES • Biceps • Triceps • Supinator • Knee • Ankle • Plantar
- 28. SENSORY SYSTEM EXAMINATION • a. Superficial sensations I. First test pin prick sensation II. Touch III. Pain Rhombergs sign
- 29. CEREBELLAR EXAMINATION • a. Nystagmus • b. tremor • c Finger nose test/Finger nose finger/Knee shin dragging test • d. Pronation – supination (Disdiadochokinesia) • Gait
- 30. OTHER • a. Postural hypotension • b. Spine examination
- 31. TO BE SEEN –TAKE NURSING STAFF HELP • VITALS • SUGARS • GCS • FOLLOW INSTRUCTIONS WRITTEN IN NOTES • ANY ISSUES CALL • CHECKLIST OF DRUGS
- 32. TO BE SEEN • TEAM WORK FOR CPR OR OTHER LIFE SAVING PROCEDURES • BED POSITIONING • SECURE LINE • CALL LAB AND RADIO TECHICICIAN URGENTLY • KEEP READY FOR RT FOLEYS INTUBATION IF NEEDED
- 33. TO BE SEEN • INFORM ABOUT NUSRING CARE; AIR BED,FEEDING,TRACHEOSTOMY CARE,BED SORES, POSITIONING, EYE AND ORAL CAVITY HYGEINE • IP/OUTPUT MEASUREMENT • TEACHING ATTENDERS • INFORM REPORTS TO CONSULTANTS
- 34. TO BE SEEN • DAILY NOTES • ALWAYS ASK CONSULTANT INCHAREGE TO SEND INVESTIGATIONS IF OTHER CONSULTANT MENTIONED IN REFERENCE • MOBILIZE PATIENT ATLEAST 3 TIMES A DAY
- 35. TO BE SEEN • GIVE PREFERENCE TO SENIOR CONSULTANTS WHILE ATTENDING ROUNDS • TRIAGE • INFORM CONSULTANTS IMMEDIATELY IF ANY OPD /EMERGENCY PATIENTS COME • FOLLOW INSTRUCTIONS ADVISED IN WTSAPP GROUP • POSTURAL BP MEASUREMENT • NEURO CHECK LIST • SECURITY ALERT
- 36. EMERGENCY PROFORMA Name of duty doctor: Date: Time: Provisional diagnosis: Differential diagnosis: GCS: Pulse: BP: RR: Pupils: O2 Saturation: EOM and pupils: Facial sensation: facial motor: Gag: Motor power and DTRs Planters: Sensory: Cerebellar: Gait: Spine: Sugar: Sodium: Potassium: KFTs,LFTs,ECG:,CT/MRI Brain,ABG: Plan of action Patient handed over to (after completion of duty): Name and signature of the DD Date and time Final outcome: ganeshgoudam4@gmail.com 9380906082