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- 2. Introduction Objectives • Recognize signs and symptoms of altered mental status and abnormal neurologic function. • Describe the components of a thorough neurologic system examination. • Describe the general assessment process for a patient presenting with abnormal neurologic function using the AMLS Assessment Pathway. • Determine the most likely diagnosis and potential conditions requiring emergent treatment.
- 3. The Challenges of Neurologic Complaints • Neurologic complaints are very challenging, especially in cases of altered mental status. • Often present with multiple or complex signs and symptoms. • Patient communication is often compromised. Must rely on bystanders and scene clues • Multiple potential causes: Primary central nervous system (CNS) dysfunction (intracranial) Secondary non-CNS disease causing CNS dysfunction (extracranial)
- 4. The Human Brain • Cerebrum Frontal, parietal, temporal, and occipital lobes • Cerebellum • Brainstem Medulla, pons, and midbrain • Meninges and cerebrospinal fluid (CSF)
- 6. Blood Supply to the Brain • Carotid arteries • Vertebral arteries • Circle of Willis Ensures an adequate blood supply should one side become obstructed.
- 7. Physiology of Cerebral Perfusion • Autoregulation ensures adequate cerebral blood flow over a wide range of systemic blood pressures (about 60−160 mm Hg mean arterial pressure). This mechanism disrupted by trauma and intracranial hemorrhage/lesions • Cerebral perfusion is also affected by: Intracranial pressure (ICP) − An increase in ICP can impede blood flow. Carbon dioxide level − Low CO2 (hyperventilation) causes cerebral vasoconstriction. − High CO2 (hypoventilation) causes cerebral vasodilation.
- 8. Brain Physiology • Blood−brain barrier Created by tight junctions and special channels in capillary walls. Prevents certain particles, such as some proteins, bacteria, and antibiotics, from flowing into the brain. Loss of function if trauma, ischemia, elevated ICP occurs. • Glucose and oxygen Continuous supply needed to maintain normal functions. • Skull: a rigid, inflexible box Bleeding, an intracranial mass, or increase in CSF volume causes increase in intracranial pressure.
- 9. Consciousness • Levels of wakefulness (AVPU) Alert, eyes open and looking around Somnolent/sluggish (but responds to verbal) Unresponsive to verbal, but responsive to pain Unresponsive to pain • Levels of awareness Oriented (person, place, time, event) Disoriented/confused or unable to process information normally • Delirium Acute confusion that waxes and wanes • Dementia Chronic progressive loss of memory and cognitive function
- 10. Altered Mental Status (AMS) • Ranges from obvious alteration in wakefulness or awareness to subtle changes in behavior, judgment, and cognition. • AMS may indicate significant brain dysfunction. • You must consider both intracranial and extracranial causes.
- 11. Comprehensive Neurologic Exam • Mental status Wakefulness Orientation Cognition • Cranial nerves • Motor function • Sensory function • Reflexes • Cerebellar function Dr.P.Marazzi/ScienceSource
- 12. Case 1 • Dispatch A 66-year-old woman is having trouble speaking and is possibly confused. What are your concerns as you respond to this call?
- 14. Initial Observations • Scene safety consideration Is the scene safe?
- 15. Initial Observations • Large barking dog in neighbor’s yard. • Husband meets you at the door and takes you inside. • No dangers noted inside the private residence. ©Art_man/Shutterstock.
- 16. Initial Observations • Cardinal presentation Difficulty speaking • Chief complaint Difficulty speaking
- 17. Initial Observations • Primary survey Level of consciousness (LOC)—Alert; patient looks at you as you enter the room. Airway—Patent. Breathing—Breathing easily, few crackles in lung bases. Circulation—Pulse is strong and irregular; skin is warm and dry.
- 18. First Impression • Do you identify any life threats? • Is the patient sick/not sick?
- 19. First Impression • What are your initial differential diagnoses? • Which do you think are most likely? More Likely Less Likely
- 20. Intracranial bleeding Airway problem Ischemic stroke CNS lesion (tumor) Hypertensive encephalophathy Focal seizure Oral abscess/infection Metabolic derangement Complex migraine syndrome Peripheral nerve palsy Psychological event First Impression
- 21. Detailed Assessment • History taking O—She shrugs shoulders as if not sure what has happened. Shakes head “no” if asked about falling. Husband reports no recent ill symptoms or known head injury. P—No known inciting factor. Q—N/A R—Husband and patient report only problem is speech. S—Significant difficulty getting any words to come out, often says wrong word. T—Husband reports he left house about 2 hours ago, at which time the patient’s behavior was normal. He returned about 30 minutes ago and found his wife in her current condition.
- 22. • History taking, continued S—Patient suddenly was not able to speak normally. Difficulty speaking words and when she does the wrong word comes out, as best as you can determine. She denies having a headache or fever. A—No known allergies. M—Lisinopril, diltiazem, albuterol MDI, omeprazole (Prilosec), metformin; also, warfarin (Coumadin) discontinued 2 weeks ago. P—Gastrointestinal bleeding 2 weeks ago, chronic obstructive pulmonary disorder (COPD), atrial fibrillation, hypertension, type 2 diabetes. L—Small lunch 2 and a half hours ago. E—Husband states she was resting when symptoms started. R—Cigarette smoker. Detailed Assessment
- 23. Detailed Assessment 96 92% 34 mm Hg 18 210/106 • Secondary survey Vital signs 96.8°F (36°C) ECGfrom:Introductionto12-LeadECG:TheArtofInterpretation, SecondEdition,courtesyofTomasB.Garcia,MD.
- 24. PEARL; no facial swelling or redness Irregular cardiac tones; scattered wheezes, good air exchange Soft, nontender, nondistended No edema No edema Alert, oriented with slight right-sided facial droop, slight RUE drift, normal sensation
- 25. Detailed Assessment— Diagnostics BLS ALS Critical Care Blood glucose level • 144 mg/dL (8.0 mmol/L) Cardiac monitoring • Atrial fibrillation (80−100) • 12-lead ECG, A-Fib with left ventricular hypertrophy • ABG: 7.38, PaCO2 48, PaO2 68, HCO3 − 30s • Chest x-ray, mild COPD changes • Head CT
- 27. Refine the Differential Diagnosis Intracranial bleeding Airway problem Ischemic stroke CNS lesion (tumor) Hypertensive encephalophathy Focal seizure Oral abscess/infection Metabolic derangement Complex migraine syndrome Peripheral nerve palsy Psychological event
- 28. Treatment • Basic life support (BLS) Oxygen to maintain O2 sat about 94%. Complete a fibrinolytic checklist. Disposition: Determine most appropriate facility. − Primary vs comprehensive stroke center • Advanced life support (ALS) Cardiac monitoring. IV fluids as needed. • Critical care N/A
- 29. Treatment • Peripheral fibrinolytic therapy: time sensitive Maximum time since patient was definitely normal must be less than 4.5 hours (3 for some patients) • Intra-arterial interventions: up to 9+ hours Fibrinolytics Mechanical − Retrievable stent
- 30. Ongoing Management • Reassess the patient frequently. Vitals, airway, neurologic exam. Continue to further refine the diagnosis. Modify treatment as necessary. Transport decision.
- 31. Case Wrap-Up • Diagnosis Acute ischemic stroke • Case closure: The patient was admitted to the hospital for further care.
- 32. Additional Points • Look for stroke using a prehospital scale. • If stroke screen positive: Determine last time patient known to be normal (baseline). Check glucose level. Determine most appropriate destination based on duration and severity of symptoms. • Thrombosis or embolism leads to complete occlusion of a cerebral vessel. Atherosclerosis Atrial fibrillation or endocarditis • Signs/symptoms relate to the area of the brain that is affected. • Transient ischemic attack (TIA) is a harbinger of impending stroke. Stroke-like symptoms that resolve in 24 hours
- 33. Further Discussion • Using the AMLS assessment pathway should enable you to quickly identify life threats that should be managed when found. • Obtaining a thorough history and conducting a physical exam will identify differential diagnoses that will drive your treatment based on your scope of practice. • Failure to recognize the acute stroke and rapidly transporting to a stroke center in this case would greatly increase morbidity.
- 34. Case 2 • Dispatch A 68-year-old male calls 911 after falling to the ground while walking on the sidewalk. Dispatcher tells you that the patient is complaining of a mild headache. What are your concerns as you respond to this call?
- 36. Initial Observations • Scene safety consideration Is the scene safe?
- 37. Initial Observations • You see a man lying on the sidewalk. • The road is busy. • It is a cool, clear autumn day. ©PACIFICPRESS/Alamy.
- 38. Initial Observations • Cardinal presentation Ground-level fall • Chief complaint Loss of balance
- 39. Initial Observation • Primary survey LOC—Awake and alert, oriented, but questions to the patient had to be repeated. Airway—Patent. Breathing—No evident difficulty, good air exchange. Circulation/perfusion—Good peripheral pulses, warm extremities.
- 40. First Impression • Do you identify any life threats? • Is the patient sick/not sick?
- 41. First Impression • What are your initial differential diagnoses? • Which do you think are most likely? More Likely Less Likely
- 42. Intracranial hemorrhage Elevated intracranial pressure Pseudotumor cerebri Encephalitis/ meningitis CVA Normal pressure hydrocephalus Tumor Viral syndrome causing weakness Migraine Medication side effects First Impression
- 43. Detailed Assessment • History taking O—During the past 3 weeks the patient has been having a mild but persistent headache and a little trouble thinking clearly. States that today he felt off balance while walking and fell to ground, but just got a minor bump on head and no LOC. P—Nothing identified. Q—Headache is dull. R—Headache is diffuse. S—Patient unable to assign a number. T—3 weeks ago.
- 44. • History taking, continued S—Mild headaches, gait imbalance, difficulty concentrating; also reports a few episodes of urinary leakage before he could get to a bathroom. A—Penicillin, sulfa. M—Levothyroxine, aspirin, metoprolol, atorvastatin, lisinopril. P—Hypertension, coronary artery disease, hypothyroidism. L—Lunch a couple of hours ago. E—Walking to the grocery store when symptoms came on and he fell. R—Related to past history, medications. Detailed Assessment
- 45. 92 98% 35 mm Hg 14 104/78 • Secondary survey Vital signs 98.9°F (37.2°C) ECGfrom:Introductionto12-LeadECG:TheArtofInterpretation, SecondEdition,courtesyofTomasB.Garcia,MD. Detailed Assessment
- 46. Small abrasion on forehead Cardiac tones regular; lungs clear and equal, good air exchange Soft, nontender, nondistended; incontinent of urine No edema No edema Alert, oriented X4, no facial droop; motor strength intact in all extremities, unsteady when assisted to stretcher Detailed Assessment
- 47. Detailed Assessment— Diagnostics BLS ALS Critical Care Blood glucose level • 87 mg/dL (4.8 mmol/L) Cardiac monitoring • NSR at rate of 67 • 12-lead ECG unremarkable Head CT Labs
- 48. Refine the Differential Diagnosis Intracranial hemorrhage Elevated intracranial pressure Pseudotumor cerebri Encephalitis/menin- gitis CVA Normal pressure hydrocephalus Tumor Viral syndrome causing weakness Migraine Medication side effects
- 49. Treatment • BLS Oxygen to maintain O2 sat about 94%. Disposition: Determine most appropriate facility. − Neurosurgical capability preferred • ALS Cardiac monitoring. IV fluids as needed. • Critical care N/A
- 50. Treatment • Definitive treatment is drainage of CSF via surgery. Initially by lumbar puncture. Usually long-term management includes placement of ventriculo- peritoneal shunt.
- 51. Ongoing Management • Reassess the patient frequently. Vitals, airway, neurologic exam. Continue to further refine the diagnosis. Modify treatment as necessary. Transport decision.
- 52. Case Wrap-Up • Diagnosis: Normal pressure hydrocephalus • Case closure: Patient was admitted to the hospital and underwent surgery for placement of a ventriculoperitoneal shunt. Cerebrospinal fluid removal by lumbar puncture led to improved gait and relief of his headache.
- 53. Additional Points • Look for critical causes of altered neurologic function. Consider SNOT: S—sugar, stroke, shock, seizure N—narcosis (opiates, carbon dioxide) O—oxygen T—trauma, toxin, temperature, tumor • Treat potential etiologies if possible. • Transport to a facility with neurosurgical capability if assessment suggests likelihood of intracranial lesion.
- 54. Further Discussion • Using the AMLS assessment pathway should enable you to quickly identify life threats that should be managed when found. • Obtaining a thorough history and conducting a physical exam will identify differential diagnoses that will drive your treatment based on your scope of practice. • Failure to recognize the neurologic dysfunction in this case would lead to delay in diagnosis and increased morbidity.
Editor's Notes
- Discuss each learning objective and the importance of thoroughly understanding each one.
- Instructor note: Consider providing examples of the some of the points listed above. Examples of primary CNS dysfunction include stroke, cancerous tumor in the head, and cysts with mass effect. Examples of secondary non-CNS dysfunction include hypoglycemia, hypoxia, hypotension, hypercarbia, liver and kidney disorders, and other metabolic derangements.
- Briefly review the anatomy of the brain, pointing to the structures listed. Instructor note: Cerebrum coordinates higher order thinking and cognition. Cerebellum coordinates balance and fine-motor skills. Brainstem controls the vegetative functions.
- Use this slide to point out the segmentation of specific functions to specific regions of the brain; thus brain injury or infarct causes specific clinical effects based on the region affected. In slide: M indicates motor cortex; A = association cortex; S = sensory cortex. Mention the homunculus—the body is mapped out in the motor cortex with a large area dedicated to face and hands, and relatively less to other areas.
- Point to the listed arteries. Vertebral arteries join to form the basilar artery inside the skull. Basilar artery and carotid arteries meet at Circle of Willis so that blood flow to brain can be maintained despite blockage of one of the four arteries entering the skull.
- The blood−brain interface limits entrance of certain pathogens and toxins, but breaks down when injuries and disease occur. Note that the brain is particularly reliant on glucose for metabolism (primary energy source); therefore low levels of glucose have rapid effect on brain function. Describe how the skull protects but also confines the brain to a limited space, so process that causes increase in intracranial mass causes pressure and compression on the brain and may lead to herniation of brain through foramen magnum in base of skull. Explain that within wide range of systemic blood pressure, a mean arterial pressure (MAP) of approximately 60−160 mm Hg, the brain can control blood flow to maintain proper perfusion. Outside this range, brain is dependent on systemic pressure. Explain that high intracranial pressure impedes brain perfusion despite autoregulation capability.
- Review items listed on slide.
- Note that awake and oriented refers to two distinct items: wakefulness and awareness. Delirium is acute alteration of mental status associated with acute illness and involves fluctuating level of awareness and wakefulness. Dementia is chronic condition involving short-term memory loss and often loss of executive function; may worsen with acute illness. Inform students to avoid alert and oriented x 2, 3, or 4; use alert and oriented x name, place, time, event. Inform students that additional information on AVPU can be found in Chapter 1.
- Instructor note: Intracranial causes: primary neurologic conditions. Extracranial causes: disruption of neurologic function due to primary disturbance of another body system.
- Describe basic components of neurologic exam. Students should focus their exam based on the patient’s complaint but must do those components carefully—some positive or abnormal findings can be very subtle. Stress that A&O does NOT mean that the patient’s mental status is intact—can still have alteration of judgment, understanding. Cerebellar function can be tested by finger to nose and heel to shin (lateral hemispheres) and by Romberg and gait (vermis, central part of cerebellum). Depending on the student’s scope of practice, some of these exams may not be performed.
- Case 1 involves an older woman who is having difficulty speaking and may be confused. Instructor note: For students other than prehospital practitioners, dispatch information can be modified for settings other than prehospital care.
- Review the steps of the AMLS assessment pathway. Assessment is a dynamic process that occurs simultaneously. The key is to slow the provider down and move through each of these steps so as not to miss an important piece of information needed to develop a differential diagnosis.
- Initial impression begins when the dispatch information is received. When you arrive on scene assess for safety threats and situational clues. You’ll be able to determine how well your initial impression agrees with your initial observations. At the scene, providers must ask themselves the following: Are the scene and crew safe? How many patients are involved? Do you have enough resources? Do you have the right resources Is there any need for special personal protective equipment (PPE)? What is your general impression?
- On the basis of the points listed above, ask students to offer scene implications and any precautions necessary.
- Instructor note: Differentiating cardinal presentation from chief complaint is important. In this case, the cardinal presentation and chief complaint are the same—difficulty speaking.
- Review the primary survey findings.
- There is no immediate life threat, but a potential for a life threat exists if the patient experiences a further decrease in mental status. The patient is sick, and appears to have experienced an acute, time-sensitive neurologic event.
- Instructor note: Ask the students to generate a list of possible problems. Discuss from the list of differentials that could cause difficulty speaking. How you would categorize the different causes? Students may have lists that do match and/or lists that are shorter. Here are diagnoses to consider. Ask students to provide a rationale for each diagnosis that is shared. Intracranial bleeding Airway problem Ischemic stroke CNS lesion such as tumor or hydrocephalus Hypertensive encephalopathy Focal seizure Oral abscess/infection Metabolic derangement (such as hypoglycemia, electrolyte abnormality) Toxin Complex migraine syndrome Peripheral nerve palsy Psychological event
- Instructor note: Students may debate how the conditions are categorized. Categories are not absolute and depend on the severity of the patient, which is not presented here. Keep an open mind with a broad differential at this initial stage. Take this opportunity to list all of the potential causes of the chief complaint/cardinal presentation. Later in the case you can narrow it down to a smaller number of causes that should still be of concern either due to their seriousness or their likelihood. Possible diagnoses include: Intracranial bleeding Airway problem Ischemic stroke CNS lesion such as tumor or hydrocephalus Hypertensive encephalopathy Focal seizure Oral abscess/infection Metabolic derangement (such as hypoglycemia, electrolyte abnormality) Toxin Complex migraine syndrome Peripheral nerve palsy Psychological event
- Review history taking using the OPQRST mnemonic. Instructor note: Have students determine what time to use to determine if patient is eligible for tissue plasminogen activator (TPA). Proper answer is last known normal behavior, which was 2 hours ago.
- Review history taking using SAMPLER. Instructor note: Ask students about the implications of the information provided. The patient’s risk factors include her past medical history and discontinued use of Coumadin.
- Instructor note: Ask the students what the vital signs tell about the patient. Respirations—18 breaths/min Pulse—96 beats/min Blood pressure—210/106 mm Hg Pulse oximetry—92% CO2—34 mm Hg Temperature—98.2°F (36.8°C)
- Patient appears anxious and is slightly overweight. HEENT: Head: Unremarkable Eyes: PEARL, extraocular movement intact Ears: Unremarkable Nose: Unremarkable Throat: Oral cavity clear; neck supple Heart and Lungs: Lungs with scattered wheezes, good air exchange Cardiac tones irregular Neuro: Alert, seems oriented x4, conditioned reflex normal with slight right-sided facial droop, speech slow with word-finding difficulty, slight drift in right upper extremity (RUE), sensation normal Abdomen and Pelvis: Soft, nontender, nondistended Upper and Lower Extremities: Extremities without edema
- Instructor note: Discuss how these diagnostics support the differentials. Atrial fibrillation is risk factor for formation of a clot in left atrium; the clot can then travel to the brain and cause an embolic stroke. Instructor note: Left ventricular hypertrophy is common in patients with chronic hypertension and heart failure.
- The ECG is an example of left ventricular hypertrophy with atrial fibrillation. Atrial fibrillation is noted by the regularly irregular rhythm with no obvious P waves.
- Instructor note: Discuss where students would place her now; use the “pen” in the PowerPoint to make comments or circle the potential differential. Discuss each differential and either rule it in or rule out. Intracranial bleeding: less likely, as patient does not report having a headache. This is the major differential with ischemic stroke. Ischemic stroke: very likely; consider this as the working differential unless proven otherwise. CNS lesion such as tumor or hydrocephalus: possible; need to rule out with computed tomography. Hypertensive encephalopathy: possible, but focal speech/motor deficit without change in mental status not typical. Focal seizure: possible, but no associated motor movements or change in consciousness consistent with a seizure. Toxin: unlikely; unusual for a toxin to cause such a focal deficit. Complex migraine syndrome: possible, but rare without a headache. Peripheral nerve palsy: unlikely; deficits would mean multiple nerves involved, some cranial. It is unusual to affect only one side of the body. Psychological event: possible, but no recent stressors or history of psychological events.
- The patient should be treated for stroke. Describe what needs to be done in the field at this point. Definitive treatment will be covered at the end of the case. Destination should be to primary stroke center if can arrive within 3 hours from time last seen normal. If not, unless very minimal deficits, consider transport to comprehensive stroke center for intra-arterial interventions, even if greater distance. A primary stroke center is capable of diagnosing the stroke and administering fibrinolytic prior to transferring to a comprehensive stroke center. The terms and definitions may vary in your area. The goal is to transport the patient to the appropriate facility that is capable of providing definitive care.
- Discuss treatment options, noting the importance of knowing when the patient’s behavior was last known to be normal and the impact of time on treatment options.
- Instructor note: Discuss with students the treatment options based on scope of practice and local protocols. Treatment should be directed at frequently reassessing the patient’s condition to note any changes during transport.
- Acute ischemic stroke Ischemic stroke is the result of a blocked blood vessel caused by a cerebral thrombosis or cerebral embolism.
- Discuss the prehospital stroke scale used in your area – Cincinnati (FAST-G), Los Angeles (LAPSS), Rapid Arterial oCclusion Evaluation (RACE), Miami Emergency Neurologic Deficit (MEND). The Cincinnati Stroke Scale, Los Angeles Prehospital Stroke Screen, and NIH Stroke Scale are covered in the AMLS text. Hypoglycemia can mimic the signs and symptoms of a stroke. Therefore all patients with altered mental status should have their blood glucose checked.
- Review the points listed above.
- Case 2 involves a man who has fallen. Instructor note: For students other than prehospital practitioners, dispatch information can be modified for settings other than prehospital care.
- Review the steps of the AMLS assessment pathway. Assessment is a dynamic process that occurs simultaneously. The key is to slow the provider down and move through each of these steps so as not to miss an important piece of information needed to develop a differential diagnosis.
- Initial impression begins when the dispatch information is received. When you arrive on scene assess for safety threats and situational clues. You’ll be able to determine how well your initial impression agrees with your initial observations. At the scene, providers must ask themselves the following: Are the scene and crew safe? How many patients are involved? Do you have enough resources? Do you have the right resources? Is there any need for special PPE? What is your general impression?
- On the basis of the points listed above, ask students to offer scene implications and any precautions necessary.
- Instructor note: Differentiating cardinal presentation from chief complaint is important. The cardinal presentation is the patient’s medical problem or may be trauma as a result of a medical problem – ground-level fall. The chief complaint is what the patient complains of – loss of balance. For some patients, the cardinal presentation and chief complaint might be the same.
- Review the primary survey findings.
- This patient has no life threats, but may be sick.
- Discuss from the list of differentials for this patient and how you would categorize the different causes from more likely to less likely. Instructor note: Participants may have lists that do match and/or lists that are shorter. The patient could have the following problems: Intracranial hemorrhage (spontaneous or traumatic) Cardiac arrhythmia Stroke Cerebral concussion Intracranial lesion causing mass effect or hydrocephalus Elevated intracranial pressure Normal pressure hydrocephalus Hypoglycemia Seizure Hypotension Sepsis Metabolic disorder Viral syndrome causing weakness Migraine headache Medication side effects
- Instructor note: Students may debate how the conditions are categorized. Categories are not absolute and depend on the severity of the patient, which is not presented here. Keep an open mind with a broad differential at this initial stage. Take this opportunity to list all of the potential causes of the chief complaint/cardinal presentation. Later in the case you can narrow it down to a smaller number of causes that should still be of concern either due to their seriousness or their likelihood. Possible diagnoses include: Intracranial hemorrhage (spontaneous or traumatic) Obstructive hydrocephalus/elevated intracranial pressure Pseudotumor cerebri (intracranial hypertension without structural lesion) Encephalitis/meningitis Cerebrovascular accident (CVA) Normal pressure hydrocephalus Tumor (without severe mass effect) Viral syndrome causing weakness Migraine Medication side effects
- Review history taking using the OPQRST mnemonic. Instructor note: The patient had a headache prior to the fall, which might indicate that he had a process or condition that led to the fall and may have a head injury after the fall.
- Review history taking using SAMPLER. Instructor note: Discuss specific past history information and medications that would make the patient get light-headed, dizzy, and fall down. Hypertension increases the risk of a brain hemorrhage. A patient with coronary artery disease increases the likelihood of cerebral artery disease and the development of a clot. The beta blocker and ACE inhibitor increase the risk of hypotension leading to syncope.
- Instructor note: Ask the students what the vital signs tell about the patient. Respirations— 14 breaths/min Pulse—92 beats/min Blood pressure—104/78 mm Hg Pulse oximetry—98% CO2—35 mm Hg Temperature—98.9°F (37.2°C)
- Patient appears anxious and is slightly overweight. HEENT: Head: Small abrasion on forehead Eyes: PEARL, eye movement normal Ears: Unremarkable Nose: Unremarkable Throat: Oral cavity clear; neck nontender with good range of motion Heart and Lungs: Lungs clear and equal, good air exchange Cardiac tones regular Neuro: Alert, oriented to name, place, time, and event; no facial droop; motor strength intact all extremities, unsteady when assisted to stretcher Abdomen and Pelvis: Soft, nontender, nondistended; incontinent of urine Upper and Lower Extremities: Extremities without edema
- Review material on slide; ask about implications of information provided. Laboratory analysis might include checking sodium levels, liver and kidney function, urinalysis, and blood count.
- Instructor note: Discuss where students would place her now. Use the “pen” in the PowerPoint to make comments or circle the potential differential. Discuss each differential and either rule it in or rule out. Ask students to add new differential diagnosis based on additional case information. Intracranial hemorrhage: possible either spontaneously or from trauma, but usually presents more acutely. Elevated intracranial pressure (from structural lesion)/obstructive hydrocephalus: very likely; need to rule out with computed tomography. Pseudotumor cerebri (intracranial hypertension without structural lesion): unlikely; usually occurs in young females, so it would be an atypical presentation. Encephalitis/meningitis: possible, but there is no fever, neck stiffness, or other signs of infection and no reported exposure. CVA: unlikely; usually has an acute onset and more focal deficits. Normal pressure hydrocephalus: very likely based on symptoms and diagnostics. Tumor (without severe mass effect): possible; need to rule out with computed tomography. Viral syndrome: possible, but there are no other infectious symptoms and patient shows a longer than typical course. Migraine: unlikely because the headache is usually more severe and the associated neurologic deficits are more focal. Medication side effects: possible, but you should rule out intracranial causes first.
- The patient should be treated for normal pressure hydrocephalus. Describe what needs to be done in the field at this point.
- Review the points listed. The idiopathic form most commonly occurs in adults over 60 and is equally common in males and females. A similar syndrome can occur due to obstruction of CSF outflow by mass in 4th ventricle.
- Continue supportive care and close observation. Transport to a neurosurgery facility is desirable.
- Normal Pressure Hydrocephalus A patient with normal pressure hydrocephalus is characterized by an excessive volume of CSF in the ventricles but normal CSF pressure when determined by lumbar puncture. Other symptoms include gait difficulty, cognitive impairment, and urinary incontinence. Main differentials include obstructive hydrocephalus and dementia from other causes such as Parkinson’s disease or vascular problems.
- Review the points listed above.
- Review the points listed above.