This document discusses several cases involving patients presenting with neurological symptoms. It includes details on the patients' histories, presenting symptoms, vital signs, and test results. The document provides guidance on the assessment and management of these types of cases as a house officer, including taking a history, performing examinations, ordering tests, making treatment decisions, providing supportive care, and monitoring for complications. Key steps outlined are recognizing stroke symptoms, conducting assessments like the NIH stroke scale, obtaining imaging, considering thrombolysis, controlling risk factors, and managing increased intracranial pressure or seizures.
2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
Stroke. 2015;46:3020-3035.
Case presentation on Quadriparesis with Guillain barre syndrome
Quadriparesis is a condition characterized by weakness in all four limbs (both arms and both legs).
The weakness may be temporary or permanent.
Quadriparesis is different from quadriplegia.
In quadriparesis, a person still has some ability to move and feel their limbs.
In quadriplegia, a person has completely lost the ability to move their limbs.
2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
Stroke. 2015;46:3020-3035.
Case presentation on Quadriparesis with Guillain barre syndrome
Quadriparesis is a condition characterized by weakness in all four limbs (both arms and both legs).
The weakness may be temporary or permanent.
Quadriparesis is different from quadriplegia.
In quadriparesis, a person still has some ability to move and feel their limbs.
In quadriplegia, a person has completely lost the ability to move their limbs.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Acute Stroke protocol of management .. Dina Ashraf (ZUHP team 2012-2013 )
1.
2. Prof. Dr / Atef Radwan
The dean of the faculty of medicine zagazig unversity
Prof. Dr / Hanan Abdel Azim
Professor at the Neurology department
Dr / Hala Hafez
MD of neurology
Dr/ Ahmed Abdul Sabour
ALS instructor at the ERC & head of DMTC
Dr/ Shaimaa El-Aidy
Resident doctor at the neurology department
3. Case 1 at the ER
55 years old male with severe headache & slurred
speech .
What is your attitude as a house officer ?
4. Case 1
55 years old male with history of Hypertension
presented to the ED at 8 AM with severe headache
& slurred speech .
The patient was last seen normal by his relatives
before sleeping at 11 PM yesterday .
What is your attitude as a house officer ?
5. Case 2
65 years old female with history of DM &
Hypertension presented to the ED at 12 PM with
acute onset of left side face drop , weakness at left
arm & left leg started at 10:30 AM .
What is your attitude as a house officer ?
6. Case 3
65 years old female with history of DM &
Hypertension presented to the ED with Seizures
occurred 1 hour ago with no known history of
epilepsy .
What is your attitude as a house officer ?
7. Vital signs
BP : 200 / 110
RR : 15/ min
Temp : 37.4 ˚c
Pulse : 102 / min , Irregular , equal on both sides
RBS : 300 mg/ dl
CT ordered
8. • O2 saturation = 85 % .. The patient needs O2
• The patient GCS is not reported
• You missed the patient silent MI / Arrythmia
.. Do ECG
• Calling acute stroke team
• Lab
• Urgent CT
• …………….
• …………….
9. • Time Zero … ?
It’s The time when the patient is last seen normal
• Previous history of :
1. Seizure
2. HPN / DM / Seizures
3. Trauma / surgery
4. Previous stroke .. When ?
5. Medications ( anticoagulant since … ? )
• Associated emergencies :
MI / DKA / Hypertensive crisis / Heamorrage
10.
11. Case 2
Your Grandfather 65 years old male with history of
DM & Hypertension suffered sudden weakness in
his right arm & leg with mouth deviation
-Will you give him Asprin ?
No
-What if symptoms relieved in 10 mins ?
It’s A TIA R/ Asprin 75 mg 1x2
-What to do next ?
Call EMS 123
13. When to suspect stroke ?
1. Sudden numbness or weakness of the face, arm or
leg (especially on one side of the body)
2. Sudden confusion, trouble speaking or
understanding speech
3. Sudden trouble seeing in one or both eyes
4. Sudden trouble walking, dizziness, loss of balance
or coordination
5. Sudden severe headache with no known cause
ACLS guidelines 2012
14. Pre-hospital EMS actions
•Support ABCs ( BLS )
•Pre-hospital Stroke assessment
3 orders ( Cincinnati Pre- Hospital Stroke scale )
Ask the patient to
1. Smile +/- deviation in one / both sides
2. Close his eyes and both arms straight with palms up 10 seconds +/- Hand drift one /
both sides
3. Tell you the time or place or ( you can’t teach an old dog new tricks ) Slurred speech
•Time Zero ?
•Alert the nearest hospital with stroke team
ACLS guidelines 2012
•Check glucose ( If possible )
15. Time zero :
• Def:
It’s The time when the patient is last seen normal
• It’s important for thrombolytic therapy administration
decision
• If > 8 hs or not identified absolute contraindication
for r-TPA
ACLS guidelines 2012
21. In 10 minutes
Airway - Check airway if needed ( Head tilt / Chin left or Jaw thrust )
- Clear the air way If obstructed and choose a suitable airway **
ACLS guidelines 2012
22. In 10 minutes
Breathing - Check for breathing ( Look , Listen & feel and count to 10)
- Auscultate and Percuss the Chest / Tidal volume / equality
If No Pulse / No breath Oxygen for O2 Saturation < 92 %
- Apply pulse oximeter ..
Start resuscitation Algorithm
Circulation - Vital signs
- IV line
ACLS guidelines 2012
23. In 10 minutes
Disabilty - Glascow Coma Scale / AVPU / NIHSS
- Lab
(CBC , RBS , ABG , -- PT , PTT , INR -- , Cardiac enzymes )
NB : Cardiac enzymes for suspected MI patients only .
- R/ Thiamine 100 mg IV
- Order CT & Call Acute stroke team / Neurologist
- ECG for arrhythmias or acute MI ( Shouldn’t delay Urgent CT )
- General examination ( pupil & signs of meningeal irritation)
ACLS guidelines 2012
25. In 25 minutes
* Rapid History Taking
* Determine Time Zero
* Neurological Examination NIHSS
* Do the head CT
ACLS guidelines 2012
26. Don’t Give
Aspirin / Heparin / Iv thrombolytic
therapy
Unless after reading CT
ACLS guidelines 2012
27. In 45 minutes
•Read CT
•Take decision according to CT result & Time Zero
ACLS guidelines 2012
28. Imaging modalities
1- CT :
(( to exclude intracranial hemorrhage ))
** Urgently in 10 mins from ED arrival if :-
Fever – Papilloedema – Seizures
** In 25 mins from ED arrival if :-
if Signs of Subarachnoid hemorrhage / Pinpoint pupil present
** If free at the 1st time from ICH repeat 24 hours later if
deteriorating neurological deficit to determine the site of the
infarction
2- MRI .. When ?
Suspecting Posterior circulation Ischemia ( Basilar Artery occlusion )
29. Decision Taking according to CT reading
Check for Hemorrhage
Yes No
Call a Neurologist Recanalisation Candidate ?
Stable Patient ? - Check exclusion criteria
- Rapid neurological reassessment
Yes No Still candidate ?
No Yes
R/ Asprin ( 1x2 ) up to 325 mg/d
Ward admission
Call Acute Stroke team
ACLS guidelines 2012
ICU admission Thrombolytic therapy
32. National Institutes of Health Stroke Scale
Used for :-
1- Thrombolytic therapy decision making
2- Prognosis of stroke
OXFORD neurology 2011
33. Level of conciousness LOC ** 3
LOC questions 2
LOC Commands 2
Best Gaze 2
Visual field 2
Facial palsy ** 3
Motor arm Rt. & lt. 4+4
Motor Leg Rt. & lt. 4+4
Limb Ataxia ** 2
Sensory 2
Intinction & Extinction ** 2
Language 3
Dysarthria 3
Total NIHSS 42
Total modifed NIHSS 31
34.
35.
36.
37. Score Stroke grade
0 No
1-4 Minor
5 - 15 Moderate
16 - 20 Moderate to severe
21 - 42 Severe
OXFORD neurology 2011
38. * Total score = … /31
* Includes All NIHSS Except:-
1. Level of consciousness
2. Facial palsy
3. Limb ataxia Depends on the patient cooperation
4. Sensory response
5. Extinction & Inattention
OXFORD neurology 2011
41. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management
42. General supportive care & palliative care :
(A) (B) (C)
1-Oxygenation 1- Cardiac monitoring 1- Head positioning
2- Blood pressure 1st 24 hours ( Elevated at 20-30 ˚)
( See BP control ) 2- Swallowing assessment 2- Body positioning
3-Temperature (for nasogastric tube 3- DVT prophylaxis
( See Fever control ) application & oral drug * Elastic stocking
4-Blood glucose administration ) * Raise the legs
( Measure 1x 4 x 3 & 3-Drugs * UFLMWH 5000 1x2
control with Insulin ) * Anti-platelet After 48 hs.
5- Hydration *Anticoagulant 4-Bowel & bladder care
6- Lab *NSAID 5-Skin Integrity
*Lipid lowering drugs Inspect skin sacrum, heels,
*Vitamins elbows, shoulders for
4- Treatment of other pressure sores regularly
co-morbidities
43.
44. Triple (H) therapy in Subarachnoid
hemorrhage :
– Hydration
– Hemodilution
– Hypertension ( Not < 140/90 )
45. Pyrexia
- Paracetamol (oral or intravenous)
-Wet sponging
- Removal of blankets and application of fans.
** Recheck in 1 hour If pyrexia persists :
Septic source?! (i.e. physical examination, chest x-ray, urine, sputum,
blood cultures as clinically indicated) Appropriate antibiotics
Hydration
IV normal saline ( avoid glucose solutions ) at a rate to maintain Euvoleamia &
Monitored via Fluid balance chart
Palliative care
1- Pain control & sedation
2- Physiotherapy
3- Speech therapy ( after 24 hours )
46. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management
48. 1- Glasgow Coma Scale (GCS)
- Hourly for the first 24 hours
- 2-4 hourly for next 48 hours if stable
•A decrease in GCS of ≥ 2 points from baseline
Neurological decline ( urgent medical assessment is required )
* GCS ≤ 8 is predictive of impending cardiorespiratory arrest
OR NIHSS … score from 42
Score :-
>4 points increase in the score deterioration
OR Modified NIHSS … score from 31
Score :-
< 12 Good prognosis ≥12 Poor prognosis
50. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management
55. 1- Angiodema
How to suspect ?
.. Occurs more with patients treated with ACEI
So , Examine tongue 20 mins before the end of infusion
56. Action : - Discontinue IV r-TPA early
- R/ Diphenhydramine 50 mg IV ( H1- Blocker )
- R / Ranitidine 50 mg IV ( H2- Blocker )
If toungue continues to enlarge
- R/ Methylprednisolone 100 mg IV ( Corticosteroid )
If toungue continues to enlarge
- R/ Epinephrine 0.1 mg IV or 0.5 ml Nebulizer
If toungue continues to enlarge
Call Anaethesiologist
57. Call Anesthesiologist
Large toungue & Large toungue & Severe stridor &
oral intubation is oral intubation is Impending airway
possible impossible obstruction
Oropharyngeal Fiberoptic naso- Tracheostomy
airway tracheal intubation
61. 1- Tight glyceamic control … ( >400 mg/dl poor outcome )
R/ Insulin IV or SC if serum glucose levels are > 200 mg/dL
2- Tight Bl. Pressure control
To lower their risk of intracerebral hemorrhage following
administration of tPA.
See table for Hypertention treatment
Target Systol Diastol
Before infusion <185 mmHG <110 mmHG
24 hours after infusion (-5 ) <180 mmHG <105 mmHG
Check blood pressure
Measure during or after / 15 min first 2 hrs
/ 30 min next 6 hrs
Treatment
62. 3- Regular neurological monitoring ( See next )
4- Confirm the absence of Pericarditis associating MI
( Auscultate the pericardial rub )
5- Monitor for signs of bleeding , angiodema or increased
Intracranial tension
6- Avoid labs or any intervention on the next 24 hours to avoid
bleeding
63. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management
65. 1- Seizures
** Empirical prophylactic anticonvulsant therapy Not recommended
As a Prophylaxis …
R/ phenytoin
OR R/ levetiracetam
** Sodium valproate ( avoided )
66. ** Anticonvulsant therapy is indicated in
1- Observed seizures / Epilepsy ( Status epilepticus )
2- Change in mental status associated with EEG changes
67. NB : Oral anticoagulation related intracranial
haemorrhage
•Patients on warfarin with an elevated INR require urgent reversal
of coagulopathy.
- Stop warfarin
- Vitamin K 10mg IV
- Prothrombinex (25-50 IU/kg) IV
-Fresh Frozen Plasma (150-300ml)
•Recheck INR post infusion and administer further Prothrombinex
and Fresh Frozen Plasma if INR
not normalized.
•Early consultation with haematology for patients taking rivaroxeban
or dabigatran is recommended.
68. 1. Ophthalmoscope training workshop & equippement
availability
2. Thrombolytic therapy
3. Stroke suspecting culture ( 3 orders )
4. NIHSS quick application in 25 mins from arrival
5. Lab Facility in 10 mins
69. - ACLS 2012 guidelines
- www.emedicine.com
- Oxford press ( Neurology emergencies ) text book
- http://www.fpnotebook.com/neuro/exam
- www.pubmed.com
- Egyptian ministry of health protocols 2012