Facial Droop
True or False
Peripheral nerve lesions spare the forehead.FALSE:
peripheral nerve lesions affect both the upper and lower branches of the facial nerve leading to weakness or paralysis of both the upper and lower portions of the facial nerve on the ipsilateral side of the lesion
Ex. Bells Palsy
true/false
Gaze palsy is a central nerve deficit and requires additional imaging.
True:
Gaze palsy (deficit of extraocular movements) is a central deficit and requires additional imaging.
What treatment help to decrease drying of the eye for Bell Palsy?
Patching/taping of the eye, artificial tears
Which of the following disorders can produce stroke-like clinical presentations?
A. Brain tumors
B. Systemic infectious processes
C. Migraines
D. Hypoglycemia
E. All of the above
E. All of the above
Name two differentials for facial droop.
Stroke/CVA
Bell Palsy
Mass
Ramsay Hunt
Corticosteroids should be started within what time frame of onset of Bell Palsy?
72hours, have been shown to improve chances of complete recovery at 3 and 9 months
According to the reading, When evaluating a patient presenting with acute neurological deficit, what questions are important when obtaining the history and for documentation?
History of trauma, Onset/last known normal
According to the text book what is the medication treatment used to treat Bell Palsy?
for additional points, how would you dose this? Amount/frequency/duration
Corticosteroids
Prednisone 40-60mg Qdaily 5-10 days no taper
Name 4 risk factors for TIA/CVA.
Increase age, non- caucasian race, family history
Prior CVA, CAD/MI, PVD, prior TIA- 5-7%CVA risk in 2-7days and >10% in 90days, HTN, DM, Hypercholesterolemia, smoker, ETOH, Drug abuse, Afib, Sickle cell, poor diet, sedentary lifestyle, pregnancy, hypercoagulable conditions
Unilateral facial palsy that equally involves the forehead and lower face. Will also include symptoms of ear pain, vesicular rash, typically in the ear canal but occasionally on the roof of the mouth.
Ramsay Hunt
Minor paralysis (flattened nasolabial fold, asymmetry on smiling) is awarded how many points based on the NIH stroke scale.
1
What standard of care testing should be documented when making the diagnosis for Ramsay Hunt syndrome?
Corneal staining with fluorescein drops is the standard of care in patients with herpes zoster to rule out ocular involvement.
What is the treatment for Ramsay Hunt Syndrome?
for extra points name the dose/frequency/duration
The doses used to treat herpes zoster are as follows:
●Valacyclovir: 1000 mg three times daily for seven days
●Famciclovir: 500 mg three times daily for seven days
●Acyclovir: 800 mg five times daily for seven days
With regards to glucocorticoids, early trials suggested a modest benefit of glucocorticoids on a limited number of clinical outcomes. Thus, these agents were often used in combination with acyclovir for the treatment of uncomplicated acute herpes zoster in an attempt to improve quality of life and time to healing of lesions, and to reduce PHN. However, a subsequent meta-analysis of five placebo-controlled trials evaluating acyclovir alone compared with acyclovir plus glucocorticoids did not demonstrate any benefit of combination therapy on quality of life or the incidence of PHN. Furthermore, corticosteroids could potentially increase the risk of secondary bacterial skin infection.
How many seconds should a patient hold their arm out in the extended position for when assessing the patients arms for a drift?
The limb is placed in the appropriate position: extend
the arms (palms down) 90 degrees (if sitting) or 45 degrees (if
supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn,
beginning with the non-paretic arm
Inability to taste salt on the affected side of the tip of the tongue is indicative of what?
Bell Palsy. Taste may be assessed by holding the tongue with gauze and testing each side of the tongue independently with salty water.
Facial palsy is assessed by having the patient do what?
Facial Palsy: Ask – or use pantomime to encourage – the patient
to show teeth or raise eyebrows and close eyes.
When a patient presents with acute focal neurological deficits, in clinic testing should include what?
Finger glucose- hypoglycemia typically presents with more global neurologic symptoms (AMS, stupor, seizures or coma) its presence can sometimes unmask existing subclinical CNS disease and cause focal deficits. Obtain fingerstick glucose to avoid delays in appropriate treatment and help refine the differential diagnosis.
According to the textbook, what is the time frame when TPA can be administered from onset of symptoms?
within 3 or sometimes 4.5hours of onset/last known normal
MAMA
TIP – TOP
FIFTY – FIFTY
THANKS
HUCKLEBERRY
BASEBALL PLAYER
Are all used to test what?
Dysarthria: If patient is thought to be normal, an adequate sample of speech must be obtained by asking patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be
rated.
Ascending paralysis accompanied by decreased reflexes. May develop after a GI illness or immunization
Guillain-Barre syndrome (GBS)
A patient presents with a deep facial laceration and paralysis of upper half of the ipsilateral side of the face. The most appropriate course of action is:
a. Suture the laceration with follow-up in 1 week to remove sutures and re-evaluate facial strength.
b. Suture the laceration and arrange for follow-up with Otolaryngologist within 1 week.
c.Contact Otolaryngologist immediately as patient will likely require nerve exploration/repair within 72 hours.
d. Attempt to explore the nerve in the urgent care center
c. Contact Otolaryngologist immediately as patient will likely require nerve exploration/repair within 72 hours.
Discharge instructions must be explained verbally and written to include a list of symptoms that the patient should watch for, what are they. 100 points per correct red flag
Headache, Visual changes, weakness of the face or body, difficulty speaking or swallowing, difficulty walking, nausea or vomiting, numbness or tingling of the face that was not present previously, numbness or tingling of the limbs that was not present previously
Treatment for a patient presenting with headache or vertigo and any lateralizing signs include what?
TRANSFER TO THE ER
Examples of lateralizing signs would include bradykinesia, dyskinesis, ataxia and hyperreflexia.
Which of the following is a hallmark of cerebellar TIA or CVA?
A. Visual field deficit
B. Ataxia
C. Pure sensory loss
D. Hemiparesis
B. Ataxia
What is an autoimmune neuromuscular disorder characterized by Eyelid ptosis and weakness of extraocular muscles may be more noticeable than limb weakness. Progressive fatigue with sustained or repeated exercise, which decreases with rest.
Myasthenia gravis: Myasthenia gravis (MG) is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness involving ocular, bulbar, limb, and/or respiratory muscles. The weakness is due to an antibody-mediated, immunologic attack directed at proteins in the postsynaptic membrane of the neuromuscular junction (acetylcholine receptors or receptor-associated proteins). MG is the most common disorder of neuromuscular transmission.