Organization and Control of

Disorders of Neural Function

ChaPters 48'54 Neural Function

Advanced PathoPhYsiologY
NURS 5104

Rula Btoush, RN, DNSc

Maior Cells of the Nervous SYstem

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r Neurons il.evc r-oA5'
I Functional information-processing cells
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r Protect the nervous system and supply { eomo'
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tg trNS rnrC- ,r.,[f .
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Action Potential oyt tzuAc Question
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r Movernent of Is the following statement tme or false?

electrical charge
along the arion
'b&..K jE
r Information is processed in the nervous
membrane to system by transient changes in the
hFb'din ;
legob*zahwr convey information
M , 1" * electrochemical gradient.
tltr i"\ r Nat inflrui results
in depolarization
ciEl\ -
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r Triggers voltage- \r
gated Na+ / K+ kpobdrofd E
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channels
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r llorns: extensions of the gray matter that form the letter sFltt
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Autonomic Nervous System Neurotransmitters

Regulating, adjusting, and coordinating vital
visceral functions Acetylcholine
r Blood pressure and blood flow, Body temperature,
Respiration, I)igestion, Metabolism, Elimination r Neurotransmitter for preganglionic neurons for
Two Divisions both ANS divisions
r Sympathetic (internal and peripheral actions) r Neurotransmitter for the postganglionic
r Maintains viud functions neurons of the parasympathetic nervous system
r ..fight-orflighd,mponse
Resprrnds when drere is a critical thrcat ro the irrtegrity-the
+di{carudr6 .L Ai C€cpqiong Norepinephrine and epinephrine
r Motor/sensory
r Parasympathetic (intemal actions) r Neurotransmitters for the sympathetic
r Concemedvith consenation of eirergy
r Resourcc replenishment postganglionic neurons
r Maintenance of organ function during inactirity
r Se.sory/motor g€clhnq g€g\xlishil\0rtt N{-cn
- r

Question
r The blood-brain barrier and the blood-CSF
barrier work to Somatosensory Function,
l. Support the brain Pain, and Headache
) Maintain the electrolyte concentration
3. Provide bicarbonate ions

l9 Maintain a stable environment for neural

function
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f pei$uu$ ,r^6
ont Su\s
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n The Somatosensory Component of
J\stc't,,t ihatue ytt{rw'/,
the Nervous System (hor4e
Jg varrrftt'r'4Qf,.rf ' P!tv(;\u\t'\
w*rwatr r Function haf vs.-co\ol
coVlVnrln'c {€ r Provides an awa.rene$s spaaial oAtt'rtatmq
of body sensations such (orvrtwrnta(A?
$h^l rrv
"{+,{^L
i;t^niwt\,tb'
as touch, temperature, ' v,nrvPnutf fatlat!$i
limb position, and pain O'Glrthi tf ,i, ivt+( r4v^V
l q,lr;to"ch
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=
ltavw*+;0" A,
r The scnsoryreceptors bwqlvt
@vn -i66\61111,rg, consist of discrete nerve
1o ctvrclrUa,i Cnrr,t, endings in the skin and
ou4 other body tissues. 1c\tr\, or^rA1
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Clinical Assessment of
Somatosensory Function
r Diagnostic analysis of the level and extent of
damage in spinal cord lesions involves:
+\Ia\ ye\Le<- \J
r Testing of the ipsilateral dorsal column
tn\d /W;tvu+tW' I (discriminative touch) system
r Testing of the contralateral temperature
sLrtrtr{ ttuS;)t; proiection systems

porr\ron ,i'o^\tu'
 Question
r Vhich pathway is used for perception, //c6v)r'(-
arousal, and motor control? r Nociceptive pain c\n$i: Ee*atve/cvt"g oV5r*
f, 7tr^
I Nociceptors (pain receptors) are activated in
response to actual or impending tissue in|ury.Nc {p\osokd "fi\
Discriminative pathways " tt tro-r ?rn^
r Neuropathic pain
: Arises from direct injury to nerves
\o,2or?" vv.twov9

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Transmission of Pain Pain Threshold and Tolerance

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lL",ltHn,K*":r*^ r Pain threshold 'xrmU -p'- ertcr-1trrr€-
&r.\\ tfcorvrl.+*anr
:osDrnotllalarruc tract r The point at which a stimulus is perceived as
r Opioid peptides painful
r Endogenous analgesic r Pain tolerance l0aezd on pqctrcLoq;cot,rrrl*utza\, I rntrrtn!
center in the midbrain r The maximum intensity or duration of pain that
r Pontine noradrenergic a person is willing to endure before he or she
neurons wants something done about the pain
r Nucleus raphe magnus u..r\d ovr qfio *o\reanQ ae {uYv^^v( +
 rilca,^g Acute vs. Chronic Pain .*ffi
actt','dhon ,{ f\rLov3,l
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a,\ouvnlUfl q 4i*11',;x,6"' +ibv\ oerrlrrA-\ caraz(
$v\ I S€^r€-{4e.. Co?h,r"',\r5
r Self-limiting pain that lasts less than 6 months- r
€ It Yl, qv:hvow,,t-
r Chronic Pain Irto +r, g\+ktit gclp1r.t1
r Persistent pain that lasts longer than 6 months ,,0 ,,
Laclis. the_autonomic and somatic responses "yy.hkr /sr,Lry
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.-\ I associated with acute pain
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-\ r Accompanied
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it r_
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debilitating responses p c*44t
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Question Assessments of Pain

r Vhich type of pain is perceived as sharp and r Nature, severityr location, & radiation
intense? r Methods have been developed for
6c,ri.n.o'i:
--.-_
quanti$/ing a person's pain based on the
r Visceral
-t-/'

patient's report.
r Referred r Verbal descriptor
r Deep r Numeric pain intensity
r Visual analog
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lgr,rro&

Pain Management Special Types of Pain *ffilo r^d\^k^r"\[VV*."ai

Nonpharmacologic Pharmacologic ' T "J:f#::".:fr lffiWh..n'i T*ff:ffi '

'Irigeminal neuralgia I{1g5 .^vri\dual gttUa,rt)
r Cognitive-behalioral r Non-narcotic analgesics 6r fepVu,rza{
rru,r^/t'Prl'w
r Relaxation r Nonstercidal enti- -fr4l Facial tics or spasms characterized by parorysmal
r Distnction inflammatory drugs rvr0*t4rr\alr& *1ii1^lgttacks of stabbing pain !it^bclcs
r Imagery (NSAIDs) Tii-Jtrt.rp.tic neurllgia rraelcr{epaadrv nn{ kf ^ 6\cohilt
r Biofeedback r Antiseizuremedications r Pain oi shin gles/hcfo es i"f.".do' bg}I\j*$]H#e ,rirr,t"ratlv'' n tr{g
r Physical agents
r Antidepressants o$cctr" r r Complex regional pain syndro*.- r*; 7or.fa\oal
I IIet and cold r Opioid analgesics Oo\.frnr I r Autonomic and vasomotor iast4[ili$ pqraa.eloq a{ ?€r\- '\antr m
r Stimulus-induced
r Morphine congenes I eitt :u"r phantom Limb Pain:'t[S'TS$ti]{riXT/}tQL-/
analgesia r Neurologic pain after amputation of a limb or part of a
limb (70% of amputees)
I Acupuncture and r Begins as sensations of tingling, heat/cold, or heaviness,
acuPressure follbwed by burning, cramping, or shooting pain

Headache oltuit6l<d
nc{r\lrtn'
igraine Headaches l;-"'p frjfi\.^* rP
olout"nr"rlg\crannlv'0t'n 4relurltr, /tcfratv'ar'an
With or witliout aura &rrer'leq d4r(rmctrnn qdsegthAtie
r Intemational Headache Society
Subtypes of migraine
Classification of Headaches r Ophrhalmoplegic, hemiplegic, aphroic, or retinal mignine
Recurring, Unilateral or bilateral throbbing pain, pt56'i\{
\-7LaMt'
r Primary headaches \dorteot
ck'nto Utt'* eound
'Iriggering event or factor, Farnily history \.t[V, st"l I
r Headaches secondary to other medical d^trr{.
Exactcauseisunknown
conditions
dlg aUC
Ot^^Cr\of& Neurologic model & Serotonin
r Cranial neuralgias and facial pain gt d, Triggered
g$&%l
r tliding frorn noise, light, odon, 1reople, etc.
U,6url, Gencralized edema, irritability, pallor, nausea and
+htr oo'$qarcn\ toacr-d s^ gle vomiting, and sweating
f)iagnostic studies & Trcatment
d\q oo \\v-i +D o othrp- Ci-dAqO
 on0* mo* seileop $"* n* obaelq ilvrArcatod !$lfrt rdt!h, !\

v qcco\ladlo tn in{aCc /inzi6wina\

+c\fu ortcoltq. Clust'er Headache Tension-Typ. Headache
?0-40 vrrrnr^'ltg
6.b pardrtl"nc
i. aV9 9-10 wu6 \nqt
r Repeated headaches (weelis or months at a time) I Bilateral feeling of pressure
followed by periods of remission I Muscle contraction, tension, psychogenic, &
r rheumatic headache
Manifestations: *t69upt ae.CuvtD €rttg
I Acute / episodic and chronic
r
\s-\rowrnlda^tiry. *t$fi.ilffi;l
Sevgre q4ilateral.orbital, supraorbital, of tenrporal pain
rd I Manifestations: ?,r\ Qt,r,rq ti.rr'tv.t

r
r At least two characteristics of: 'tltqr\'0tnrlil Tti: I J "vfiri!-'', r'r
At least one of the following:
r Coniunctival iniection, Iacrimatiorq Ncal congestion,
r Pressure or tightnss semation ! go"y uloruz I u ltiut'ltt *
r Mild-ro-modente severity /v.^o)il t.f
Rhinonhea, Forehead and facialsu.ellirrg, Miosis, Ptosis, Eyelid O\it.v$I1,€(/{ {tvlr"\[\'@1ii"
r Rileteml locetion
edema
r Womening wiG physical activiry
r Diagnostic studies & Treatment Diagnostic testing & Treatment
ceilce\fr o.t sgvrjtunr5 ga'rrr vrud\a,rh 0n
Frr [u qe9

Other Types of Headache Question

r Chronic Daity Headache ,'ei{aai[d d olr'4 o;r'-'rr'r
r Which of the follou'ing is associated with
r 15 days or more a monrh *.*[tffi;ffi1,.iil; Nh,intrr','i
1g-1.9i51ita
rl
,
grinding of teeth?
rTemporomandibularJointPain v6'$^ r Tension-type headache
iWfllr.Urtnr.;f
3o,rk . f"Ji?iffi$"i8ffi, headache, neck ache, or r Cluster headache
mOr€.tnf,,rt\ earache r Chronic daily headache
r Poor bite, bruxism (i.e., teeth grinding), or joint /5\
'it.*potomandibular ioint syndrome)
problems such as inflammation, trauma, and \
degenerative changes.T5

l0
 Organization of Movement

r The Spinal Cord

r The Brain Stem
Disorders of Motor Function r The Motor Cortex
r The Cerebellum and
Basal Ganglia
r The Motor Unit

Skeletal Muscle Disorders Disorders of the Neuromuscular Junction

I

r Chansinc in the releasc, inactivation, or receptor binding of

tfiffiff"ff;;;' T^hgJT,ee, s,.n.,rr c,. ;, J
""..r*trriri". 5i arlr.lo'vz'J{*w\ {b l't rt't ocrl -illilnsor4^\

r If a normally innervatid is not used for

muscle r Drug- and Toxin-Induced Disorders: w.u$c
long periods, the muscle cells shrink in r Cunre rcts on the grstjunctional menbnne of the motor endplate
acr$t \
to prevent the depol,arizilg effect of the newtransmiuer'
diaLeter, lose much of their contractile protein, r Used duing mmy types of surgical procedtues IrnAo,n
and weaken. Clostrirlim botulinum blocks aceglcholine aud results in pamlysis'

w
r
\osc s'( vh''r!d4 z'g'[rs' r AtdcennwFA
Muscular dystrophy Myasthenia Gravis
r Autoimrnune f)isorder of ransmission at the-lgul:mbl
r Genetic disorders that produce progressive iunction that affectr commmicatiorr
betu'een tlle motoneu"ot "td
deterioration of skeletal muscles because of iffif"-nt..l ,.uscle cell (altibo<\-mediated loss of uetylcholine

mixed muscle cell hypertrophy, atrophy, and

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j,*)gtrfr*ff$ffimmn" Question
;ffi il#;il;i;*Xff,pigtf;rf n I
ca\ ta't1 <r
Lead toxicity would result in which of the
Mononeuropathies
r Caued by localized conditions such c tnuma, conprusion, or following conditions?
infections (e.g., herpe zoster)
r Frach[ed bonesmay lacer ,5'\rvrvr- Mononeuropathies
s**""," ('&"ffit[Xiii'i*3\ otai"' ruarrc)
HA*
r carpar rumel W TvLcJr€ lts
Polgreuropathies
r Dem-velination or*onal deqenention of multiole perirrheml nerve
Upper motor lesion
that lgds to s\mrnetnc se[9on. motorr of mued seroomotor
deficits
r Cguc: Myasthenia gravis
I Imune mechanims (Guillain-Batr6 spdrome) molf cotarhgn
r Toxic agents (arsenic polynewopathy, lead pollneuopathy, alcoholic
pollneuopathl)
r Metabolic diseases (diabetes mellitus, wemia)
r Guillain-Bcrd Syndrme o,c\{C avtllinvht^r\l g4oonr3oag lertunr ?A\n- shou\dr. o}vr4V rbacV,t o6tedq-$^+9
urca[rrLs6 ws \*nd"i c.S"r \ ocr.wxl9\rj\Jer\ { "i^rx*r."US

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q --e-:.\rfq
r\l
Question VAtc erniated Intervertebral Disk
J^$t
r Demyelination is the causative factor in or. UOut erve Root Iniuries
i,rl ,tb,St,
which disease? r Ruptured intervertebral disk
Aqtl
r Parkinson disease CUn r Sensory deficits
wd(
r ALS -...-- -\* Awgn 9ru op \l${ r Spinal nervc root compression

.@ C\15 o\tqsdernao
r ltruesthcsias and nrrmbness

' nr,ilnthrftu\ \ nnea I

r
Panicularly of the lcg and foot
Knce rnd ankle reflsres also mav be diminished or absent
p(riv1
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o{ ga"n
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Disorders of the Cerebellum Disorder of the Basal Ganglia

-frtf2'n4g"at" g*
{rrtrnOva.r

- cr*dooM: drda^ia I Cerebellum-Associated Movement r Characteristics

&ovrrfrttiOn al Disorders r Involuntary movements
qrrveinw.t
r Signs of cerebellar dysfunction: r Alterations in muscle tone
r Vestibulocerebellar disorders r Disturbances in body posture
I Cerebellar ataxia or decomposition of
movement g swal\u,\^q d^{Thrl}.^
n{ttwic -b,^ct{&
' ft\O{t6ah* o+ r Cerebellar tremor
&* ( \t"*tr^r,ar - s\u,r/slw.pqN.{,fuctr
{1pta/a'e5a7* r Problems with chewing and swallowing "^tfflh$ .vnrversg*
\ \rr.O.nUsg Vo\4\
rhd^& !$ (dysphagia) and speech (dysarthria) Cu,a 'JotY..t!t
l\!^r
^J\vcilvr(r. FtrEwtr.e: { o\*1 s,,xq,\34tn*r.*r\
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riyrwrunr dictag{
nohc q,,,*ahon
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v $ls'
,
r Progressive neurologic disorder that selectively
Slo^,fEf inihdhorr IIIAI6rtr -'.affects motor function
cr'^d e{€a{ho'\ survival from onset of symptoms: 2-5 ps
4 vtm^aCL
Locations of Motoneurons Affected by ALS
rrn6vg161 -t ucflcaan,' --F
5Q. t Th. anterior hom cells of the spinal cord
{.+oV ir \vru cirt,rl3l.l.t *o{m?4,1 4tf a ffr" -o,o, ,r,r"t.i of the brain stem, pzuticularly the
nuht
J*tAui:ur ,,*hrrhn UMNS of the cerebral cortex
wd\V.n\l-r^*'9 of LMNs leads to denervation, with subsequent
age of musculature and muscle fiber atrophy.
mt\aru1 sFri'ch
\nr^lnt ftwqd ^tkds' tment I eqpr
\i^qalg
+f- S4tirptuwr 1h..,Tannqg {,rugcq wonla,nr+,
stnnnll d,ir(t*t,1 tv-toL\rre"
dgr!hqq0d0\^ /Lcr.p\a /\roc4l cov{t
\ $fa**1rdo\ne,

i **qvtoE\i 1e9y[9 9 e$4<,t u e =t arln i'^"*,.r,,N

P rr'o\rrr qiaa,ro udp$ctr,'lt_
{S-a4o&r)\J\-13
 n'r119^|ff1f
@?*ic'qinAte4tr +gacchja^:a\u^r'rro
ffilffi;\*^- - Ji uat
fiY"'ffi'T-;fiil-*
dgv$\d,v'{o^-gl^eo0g .^ oht( tmr*ka-:

-ga!/4ab0\621aac+
Multiole Sclerosis (MS) .r ; Spinal Cord Iniury (SCI)
w gnrllrn t
r- c;ii"rsarrlBll wL \urxl tffimffifr!:*ffiil"P*.Y:tt -\rtl-otk r Cord compression by bone displacement
' tjg baYdl4&.
r"rdr6l-ts,qh^il,t\
Most common nonrraum",i"
" ".r.fJf,ff.#ffi
U .1'*"qe\ r Internrption of blood supply to cord
disability among young and middle-aged adults
.tglq^t^g- C0vq
., , r Penetating trauma. can result in tearing
Periods of exacerbations and remissions over many' f nrv\l \
gmc {v.nc'tmn{
$ years in several different sites in the CNS qct \wrrmdlrr- I (e.g. Gunshot, Stab wound)
.'' tunol 4*'
i,"- io;.r ry i"6"1 a"t''*i 5,- 45oro
n
t6\arr cculaemt f *
-partrutc ctt\.0\.lul
:- **n:;:" m; #;il: ::':(lsxf?::ro;
-$or"" -'F:"irlersvnir+€ siq,r, e\ i&A st^'o-lr.
r Secondarv iniurv ilr,rrY ho.r'ptrra 4c*\ntnd qrn
r ^:'"'"".-*';fi -qe-^^ uirOUg,1"*nec c^'iii$ r*f*.,cAa*ra i:cttma
1oqfi\ontrriVvro$on
C'erqltFn l)iagnosis \c"idttt^tu \i\.< {rutnnorthnf &.:n
'+t+€6"^t. V 01' r\;4€6,\o,ta e^w\4ge \\nsoaet\le
PtrVhrr,rc Z I -ratLd \rge1rio,.itA t 1
Tr."*.rr.rr1 -*d.iary1sq6' s,^sqla$(6 -\J-i"^rr* \oaocaJhAohq^
I r,rlo\L ,gurr.b +.*qs%
+l*ur^stit {t*til\!-
{tx14v\t i'sirrrl\
i'uzetr-l.r a-€:urr:rtr'
a-r9.rulr',trt
atffi(o Aosrwhna r^'..Jau^irnf rt .rOl(
.-r..-i:im.rn 6ni1"*",*t.,,.^el"o"r'l_
."YY:)-gT'r es.^ ctn^\o',rca\ crrd'r''a{f Ygtrftt
a5$o-sat^naoe { rnrceotis .to trrrzecur^aiy
vc;"to\t)urudnojnMo

lary".a-lro ftril-co.A {-5 ,^teri,\fF4\ iq5^1

$\n$dcdnwuge: '-t,*.rtt't @ Spinal Cord Shock u 9>a73 F<laM
-\sr^t \^11ona
\a{wcs\loo\c awaa\ iornrAz&
6irO9.:bradfft
.v.^rrr9rA ; sdt{a.tqr ct$qk ,P+*.f f4.*t
3fs'{-tea {*)p r""-"1x4
@,tkg dePTn\ u
r Lasts days to months
{-
#
n*"q;
'lnyt^\
ke:
R$rya5 r Characterized by: t60rU

hq to {-!d; hypoxia
secondary
:s"."tri;
!rr-an'trtticdrt"r o{ w l^ittll Loss of sensation
injury
{*o{vr.ffi^n s ,l"Jo or / r Flaccid paralysis below level of iniury
cwr{g-a${ra,ry r,\&qic4Mn4it
'lrofi*i1r.r- 4uaendila#n ttl$naon
L€I
St'locb taeig
$V,h"tn
'-rttru.n

t4
 Spinal Cord Iniury Classification
Management
Level of iniury
CAAICfrL s\<Qfal ikmu'urz {-y
r Goals:
r Ileduce the neurologic deficit t Sieletal f' Neurologic leael
r Prevent any additional loss of neurologic frrnction r Cervical
r Stabilization:
r Nonoperative: Traction & Realignment r Tetraplegia
r Arms are rarely completely paralyzed
€rey$1y
p6a6'pl #. ;^Tfr:i*illll1,k"
r IV drip
ffi11i,1[!u,'
for 48 hrs, begin within 8 hrs of iniury r Thoracic 1
\ yoq^orto r Improves blood flow & reduces edena
rLnmbar . )PanPregta
r Vasopressors (adjuvant in acute phase)
r Maintain arterial pressure to improve perftrsion to spinal 6;boue Iutawrctc \rer Q/o.t\h'u4
cord ^{Gc'tg

lwE *dov- Spinal Cord Iniury Classification

lnHo^*\nt *^o Spinal Cord Iniury Classification: Degree of Injury
Degree of injury
6,1r1k{qMrl ,aid r Complcte cord lesion
r 'l'otal loss of sensory and motor ftrnction belou. levcl oflesion
Y\",^t r Incomplete cord lesion Syndromes associated with incomplete
r Mire<l loss of r ohrntary motor acrir ity and sensation, leaving sornc cord lesion:
tEcts intict
r ASIA hnpairnent Scale
r A = Complete: No motor or sensory function
1. Central cord syndrome
is prcsewed in the

r
sacral segments S4-S5
l| = Incomplcte: Sensorv hut not motor function is presen ed bclou'
2. Anterior cord syndrome
ncurclogic ler el and irrcludes sacral scgmcrrts S4-S.5
r (l = Incompleter Motor fmction is presened belou'neurrkrgic
3. Brown-S6ouard svndrome
cqru 5
levet and morc than hall of kcy muscles belos'ncumlogic level 4. Mdrr\\abis arrhc?wr4
harc a rnwcle gmde less than 3 5, * Cauda equina syndrome
r D = lncornplete: Motor function is presened belou, the neumlogic
level and at leut half of key muscles belou. the nerrrclogic level
har.e * mucle gmde of3 or rnore
r Ii = Nonnal: Motor and seroon' funclion are rxrmal

15
 -&€tg ca'{t86il
vi/vtHsa4
'W"fg "t'"
$9ruvpo
\lyro^.stdhc
lf .ry,a,r fial{<6,a}'
n"tuFe'r$qytfrt
- ftqe a"rd
s<rtrht tnohott
d.4$a{€,
_ 6nno1i\
{tnm.e,e\Aaotr1I;
sgr"r'\gua44q\ff^g
ad{fuelhg

anrnagcfun -qaA
a.r*cu;u"e-/u
!t
/b4 I q@5gosdblncomplete Cord Lesions:
- \orc" vr1ohp. -[*r,rdio,r
ta\Md,ev Conus medullaris syndrome
- t{sir{otephi'.1 w?e
- loor rf pq j{rrarrir i Damage to very lowest portion of spinal
tor ogpib crtu (conus)
\_ & lumbar and sacral roots
\tcdrn+cl * (cauda equina)
r Flaccid paralysis of lower limbs
r Areflexic (flaccid) bladder, borvel
!, Cauda equina syndrome
/a,na6e-*o trlwlo$vr- gacraa,\ vwWe aord6
tq€ o{ nsXov.
*.t"" *l Adw sa^€orz\ {uncticnt
.€ |11EEig -{{aaid gaurlqu5,

t6
 lo:*' et{uuctlo,n fap,rUttrl o0r aur,\ttlvie^\, i"eea\
rodild
4 $'ra\ crurol i,4ju"1 rM \wmft?:ffi.dffiuru-.
-5 aqd, alAJc
ardZqO^Hr^ncnoyt Symptoms, degree of paralysis, and potential for rehabilitation Clinical Manifestations
ct
atthnd.wru, ao1
g*u\fifra,
e\rlw
yvrO.iOrrr&r\ depend on level of lesion
r Respirarory sr*..*ct- Hi-ffl*ilffiS*^*
r Abore C.l: total loss of respietory nuscle fmction (mechanical
Ca-Co: ,qrr'.e
q) U1.- ltig atoAuctto-'n ventilation)
L>-L5: onoPrunt 4 t
Cbt$- Flsa^\t T;l':;;;l,li,l u{i'|.r< ahvre
Cardiovascular System: AN9- gccbto^, l4vlannc1 vmovn6blat
frove cqftffi @u{rDl r Above T6: decreced inltuence of slmpathetic t.-o*
Bndycadia, Periphenl vasodilatio'n, ilyporcnsion
Jy","-{{}
* *t"J3€ffi-' -
Ot b"\* CIt{<o6
,Cen'ral
Thermoregulation (Poikilothe.-i
r Body tempemture = rcom tempeBture
r"rl
ur{\ €;rNGtslDs
iffi
{ drc^phaoqm -pr r Decreed ability to sweat or shiver
,gqqkAt& ce-tfua l.5f,t0^i{
tlr *'nu$vo'at\\ )\ruq "."H:::iTlH
ulces
l".ff gf;ifi'g5prs. is,en,ion, s,res s
-{
-{Hiuric ar"a-Irde $e0alqd0adn4 "tqft*d r Newgcnic bowel: less voluntaw ncurulogic contml overbowel,
rr'sr rtIA'*k tsowel is mflexic' I sphincrerone
*6s4f, sioti*r-tev$ -----
-!+rsd.t.9 +\o.rt^\r-'r
\1bc\oi {rttt{*u Sx
{FqiA
I rlirr o€
&*mr#" .t elonf
?ed BG-t.t: o<ad \vi1ut.l1 'fto -a.lac^r<

tga.eautot )l Clinical Manife stations mass\\re Als ..Autonomic Dvsrefl

\qcPotcs\gdtrcn \t/ fw.l*sffik"Y3^#;ffi,TT
Srir"t ernearhOt/ Urinary System r Acute emergency
46a\^St
Waxw o? r Urinary retmtion, Bladder distension, Indwelling catheter r iniur at or above T6, after spinal
Occurs with injuries
lo\qpowrinnrraa Integumentary System i1 ;hock has resolved, and years after the injury & .(ceq- r. qgo,/ntoqrv.q
r €Lv?-t!a
t p-rsv-€\ tr Pmsure ulces frcm lack of movement
Peri pheral Vaecular Problems
over bonv prcminences
Vr:rvr, aggerated autonomic nervous system responses ct ov(acc

bB{^A\,\ carf{i$
t nff/c"tr.lltvrara\r r f)eep vein thrcmbosis (DVT)
r I'ulmonary embolisrn ?t"\, Sq'Ji.r2z r\iv,,, r severe pounding headache, sudden increase in blood
eirvoVe'un J . pressure, profusc
.;-tln5{trc$rd diaphoresis, nanrsea, nasal congestion,
Metabolic Needs {4.*NToa, 11
bradycardi a
r NG suctioning + metabolic alkalosis \q6 O( oAd t J[f \On govrt vount\
r Triggering stimuli:
J tissue perfusion:+ respintory acidosis CO2 l:xr\dS Up r distended bladder (rnost common cause), distention or
Ioss of body ueight common contraction ofvisceral organs (such as constipation), or
A4A9 stimulation of the skin
t0srithhol
scAuci
hd,t,tcr- tatud tsv.4*R. @*aR--
.1,, $PAArra\ .- ttin{er{^ tr+rk/eU{ a4tl^dr,t
u,rte\ Coiruorlr n^ta {\tdea\o"i$( OSri"- di*"\j;i
-Jrrr^t5
OAng\\on(91ettalg oqjant oono," +,E* t""Y/tA l7
log+11
@ a\ i""qatctro'n
$c?Ca\ -\iH'6$etthth
iw\PaCnO ' \ulPtcru clt c
lrtD'pe .Ffnf euc^O,,.a*ton
 \r1trigus r^necnnrrrsrrirj lr,r,* cCtrx ba \';r-*t i.'ri,'[?r,r

Mechanisms of Iniury
Hypoxic Injury
r A deprivation ofoxygen with rnaintained blood florv

Disorders of Brain Function Ischemic Injury

r Reduced or internrpted blood flow
r Focal cerebral ischemia: strcke
r Global cercbral ischemia: myoctdial infarction
Excitotoxic Brain Injury
r Overstimulatiorr of receptors f<rr specific tmino arcids
that act as excitatory neurotrzursmitters (catecholantines,
nitric oxide, free radicals, inflamnratory cclls, apoptosis,
and intracellular proteases)

-?atE - Y.1ivr,1fo4 syat-r rO , \a'.u>tl

;!ui! hnf s\uw,h,ut O Srkkh Pn i0/. csF tD' .t, ',.\;-'v"Q,

t^,tctrstro +t
COa -o "qzct,l
t*.
varoo\\chorn Cortlrg{ -
Ourinr steWtvruc' d%nt tD-Jftt
wrnmoia fc02 t ,roGodi\afuo n \,brtaloua A ).4t-
tlar *x:
lc.errruo\ uorftuion n.^^o[Ctt] Intracranial Pressure Brain Herniation c&FrusFg4'v\+t^eoag1
$+r^e uitwrcn rl*ste |.Y;f,yf,4=+r-roo *,.q'240 qir/.\
gulate - U aof da.togrng
w.lrdatvt^/irr+hrtrhrtb
ccrvraic Avrz\\clz +
Cin
Vrriacori*u r i/\
Increased ICP is a common pathway for r lrrvolvs ccrcbnl ancry
ttce {t vnani*oL
td rnalreg eo.do\rrlr
glrr\0t!m6.. a wc€ fonos\aawnaA
*4'1 cal'rxa
ttk;*xnmelH*FTns,sq'
C,ieiri.5tcnolrcpq et
reticular ctivating syslern and
Sfbrain tissue, and -l
structures fcoohon- l#.,r"fh.fi ",gmottuwg/
damage to delicate brain wro\oc
fliN\.
'{o.fi{ trn bucin: it r Cranial cavity Incal .cs\\Gtcnq\ -U.rp\ d,r\cd, .c,
CSF o{
.

se uY, onr ..7 r l0%r blood,80% brain tissue, l0%, .

g0e6 Inn.h
"l\ft?{Blfffi l'.1", o"'1,-'ro.
3o
jn^in.ie {t r Normal ICP 0-15 mm Hg i,n lakra\ vevtltzicW
nen'e, ynstcrior ccrebral arteru, cercbcllar
tonsil, respiratory ccnter
r
$o.'', tur*roafc r Monro-Kellie hypothesis Olinical signs: hcmipmis, pupil dilation,
lisrul field loss, mpiatorl- anest
ts'lsocr4 {nitb p3,ilCIhcill' ,r\\Frrctriivi b! \i\LiL{uq:,/ t>5
ir,\ Durtct?- to "{
.1, bmoafnw -to r.nBtivr $\rL!.itil" Itr.i\ 6v\

lri^tdn vvrn\as pcobtrrn -tesut sl€ t t"^t' "1a'euvu,fuwn*5

giraknar\ 'it yli,vti'c", -t 40,^\\ii{i,.1 d
ItErno'|,uq.' c{u\u "-\,, l.-S I 6V\)F\c'i+t\r. +r'r:'
ttlJ0'ttR- i'Atbwdrnhce,rr- ?ecs,,etrc.e -L- o e- *eay"rzr,ta,j.!- ;r:ir,
- la\ooA vo\uv\e t., vqsoatilah0v\ {chdrgo1rtt'rrrdt'p+4\61 ii,.* \ lr^./i v.rir\.,
1,,,5.\'-'.v,
l8
1)itu:a.r,,\
drst0ucbd *torn/+rwnore cs\Wglilu -rf aCr.i ti t\ . -7. aaqiquzgz.;.; e
;,, u..t.r, r,,1 A+ K ( Yzalf LJa s
- CsF t . 46i g$S_T/{, "vooapno"r /ao*'nr,rA
on
 c% \r'I
+rzovfl o\ncyv"auctron/.u <rbcoernony' blacva oe
Hydrocephalus

r Definition
r An abnormal inctease i volume in any part
or all ofthe ventricular system
r Enlargement of the CSF compartment occurs
I Types'.vr,tgairnd
r yPcs'.vr,tjairnd re 4ad\c!u.od vrlil
b€ogf\aA -R2o'Yt a*eadup'd
rreabsoeg\-an'$/ro/4 l*to ut
vtr\'. iwto a{6Y}a!' c1556&&'d
r Communicating c o&r r nrainsitlJ64anoma ofdeor A S4,)Art

^r..'*t$tlt# ffiHf*n
r aQ csF f, ifi 5 7','aQ\6 m.r,;61,:.,,
Decreased
r Noncommunicating doghauct\Ot^ "abe,t ncfive fto6 @rqarn,-y4_
r Overproduction ofCSF v.ra^\rbe*.a,iran. /
itu\<\^ou?eh^oe
-o@Slnfti,{^ail,

vno*f.r aslsrctcd C S\4r'.\i {x 1!t" 4q{G.atrs

oct \t4llle cbu.ttquta@ +co^P
-t{rn -t' cav(fr- OUp
cf,
Head Iniury uir-Contrecoup
@1 r Coup: direct contusion of the brain at the site of
external force

'! BisE tboat^

r Contrecoup: rebound injury on the opposite side of
Aandge the brain

t
,d &"
/llfi6'r tttEsq
r'"-'?r*x
1*t
roi
,'fffw' .@, I @,
i,i 'I

+ i r,
:1

-''

{-*-''
rleadinlul *on{cs+rttr+auwaqs *ot^rrttar.,4 bcsoQcohs.i(j,|f,srus3 eten r( qrinoc_Wad
b"s
"{ i,*.i*o^,r. {oun^ra, \ r*.,a "i;il;i;t";;;.Iil;ffi,.,ffifffi.,^, l9
%ffiW
c.\Cg -fr\&cot*/h,,^iu\.O\o--'-*,',
U.O,* axaaa\
tqtuacvulaca\
ir^1 uraq,
valahrrrtr:arrio vr,di*.,rph
e\ \rd^l*adl.\etrfurza\ opacJnno\rl
or1
hwroedra4e
 zf.ai6'trct
{auea
gorPcra b\sd,
Postconcus sion Syndrome A.\ €\dr{p. +l^aru
\^lJniJorta corl*
\4 rc? tos-"
Concussion refers to an immediate and transient cf t o."c,Lho., cuuaciourg,nr96
lun
loss of consciousness accompanied by a brief a
,tr:$ yoeth^c\n9
period of amnesia after a blow to the head.
Recovery usually takes place in 24 hours. eAV
(-odr {o
ftffis"#^
Mild symptoms may persist for months. lt$i^'\t wrok cbvr^rm€n in
r lreadache . L'g{$1}$) a t guoi'; epee-Cr3 ,/alcok.ol.li45j
r lFitability \\ .trO\
"ow S*rS Qo-g.'.o-,r,*r
qOo9ltfi't' w lAE na"u*tstatog
r Insomnia tq,u,'olronn wtril h{rtt-; t \ce
r Poor concentration and rnemorv - f,,crtl \(t vlvrFt . C! rlr,t{S' 4'tgEaaet@
*$,lr.Je6tA cafrf' tf l'lJul hrctuogglzral16 s\gr'ke

A5A {- 9upz
Question
rc.
CowrOt Levels of Consciousness
t4aFraong.lt
Rotational acceleration of the head
u.Aal d
Ve<Owerc
result in which type of iniury?

-th.

qYtqA

20
 bec'rot
t"tik
{i\6kd debsain Other Manifestations of Deterioratin g
tlinica\ Dr: c.tao'rlrl h rEege\trot\e4 €t \€A€f Qlna+teke

Brain Function
|wgf":s\&trre"u?Main
atr*p ler- Death

r Pupil size and reaction r Irreversible loss of brain function

q".i\qt@aV + r Absence ofresponsiveness, brain stem reflexes,
orticate or decerebrate posturing
and respiratory effort
r Altered patterns of respiration. r
tu$cal6*o* 'M e Z ttrcattnu<i g"tftun=
teca(Vtrnq TEtWr^'
Medical Documentation
r Cause and irreversibility of the condition
laor plaSrroerc ata\ ='ugrrrrniaQlequtna; r Absence of brain stem reflexes and motor responses to
v- -?
cs.ft*aee geaaurcee
;Iod^Y,ffi;;;";;.d
':-,"pffi;uH?f'lJ
Chull{o.€'to9€s

p$ ntclutla : rrnporcl(vratd ,reiir,

r
pain
Absence of respiration with a PCO2 of 60 mm llg or
more
"+ . i'Pe9'^\aR r 'Ihe iustification for use of cp;r.fp1a.tory tests and their
'niaV,m results - Lo4rr{vr\tohrr\ t7g4\gApttrm 4 glu:ldE O 'r.rl
ttr\ivra e
u,r\\rt
tarl""t".r.""6a u{.rcattio"r 7 -i
rVbvl
l€'o{D?e i4 b44i{ ?^oertc\wA
* .scrhatrt rlgorzq alrepakrrhat j 6
O\Mwapa^.F+ dT - €V 6 4-wro5\' co,.*ut,., lo i,:r7;ern Wa\^*{..attr-
?c4uie. c.? p.Fll,rto! gg q7 C.6on^nrtla
tu. {*^,, t "*,q -sfrrtunta
vzqahhre
b\Dod{s(o co.'rfto"ni*d
nuucr,g /".cc
-h,,1\
;ffi:"fllil^Y.?e%tve s, :mmg tCoa-
'Wrrf
Cerebral Blood Flow
"*. ce';.tala\ dit frgs o,lotp r*ehn*.t aahFc$\A|o
l' dzFf,qqrg -tt.m bt"-t+tr^/t
tard tg|ae r$c?.yts
!{tilr'v*al,c
ti€;gftlrrhS lf T\cr.rts Fe +{TrJ audo W4r
+tTlJ .anl@bardallor
r Diagnostic criteria: tu"a+o^t r,ergeglifpx|Sft .

r Absence ofawareness ofselfand environment "**nyf*^drir,iae.tra"-.ftct

Ouniar $ev)te6Vq{q q oi
\oc6/poo€,era^/a IrL
T3f"l*'Pe*"%l
Etrv
\Ayqoblu. s?r,rdcogd
r An inability to interact rvith others g Ocgtad f.4t{lAWe r Sympathetic stimulation
I Absence of sustained or reproducible voluntary r Metabolic facto$
behavioral responses
r Lack of language comprehension
r Carbon dioxide
I llypothalamic and brain stem function to maintain lifc r Hydrogen ion
r
Bowel and bladderincontinence r Oxygen concentration
r Vrrriably preserved cranial nerve rurd spinal cord reflcxes
r (londition has continued for at least I month @tvce
c".n uzc d\gmd
Ft(..ta+C E Veq*aX,tV

2l
 ) oyL 7 6*<)
4t'.?hod
Risk Factors crSw*t\rrrre$&
louau1
r Hemorrhagic

€r{lo\ic -tre*courc
'.E+@J+q
r Diabetes mellitus r Obesity
,{aniinaHn*ro,,r
p z{o'ur*.tr\
k:
t tryain-"'naiH+
lt^lthr-rrco{run : lleart disease, atrial 4!^L^t\ to 4.ry'l
GcrralWt ru$tr'a
trrto fibrillation I Heavy alcohol
tfrrh .|p 4a "&iC
a. e\e6!a r Asyrnptomatic carotid consumption -t'.$" \nrpio$. C<c1y1uri+<o^
r4Dr'*.a'i- srn sc €1
&'It€e a+€rd{do\ic stenosis r ff" ^t
CgoVr arh tvzc{*ayr
Oral contraceptive use_
r Sickle cell disease r Physical inactivity
*rc&o, Ccrobrd lmbolk rmkr. An mbdus 'c o Eclrdggk .16k.. a boal 4r Hypercoagulabiliry
plry
iE'i6'llr5 ol tl:
colled
&por;tr co[ed
orFy b/ ftxt &porjlr
Ploquecrncw*fl cloto
Gl?l6lti-oG* de&ir <ntvftring tr''oql "esCnEiri6n blod t
\rvtm rt rshel
tfu blocd \ffim
in ttn
akyin fichointldir bM'@
on
rsher on rff ie
r*p ie o^d doqe
dorye lvoin n$Ei
unrilclol'ng rhur
nrsu
oll*E lmL
4 \pcctrdeleec^4wriA -.+-^J'ffiffi*
-{ i:I
tum *{rkhhJ.xl*thcsrxrsof
blcxi thrwnh *p or lcrv
htns*vqh. irkifursilsF,rd
iJxkr tlc fl* cf blocl ",;;;la)T

co,rc,aonzA od\ ud$\.dl o{!r

r,06rarnivg1 a,.-61rr1
ge ?pfiv,Jo,,s
(Wet go'\ "*r.cc,.\a Transient Ischemic Attack (TIA) tw\./ \ttl
.;[ icta o(ira*i ,-rl\ u,e,g

ffi/-*ilt r Temporary focal loss

caused by ischemia
t!69. in
t(469,Ui+ic,r
t eqq (v.e,etia,noja)
-
Gfi^c9i6\
-&?$Lffi'^i3:
Warning sign of progressive cerebrovascu
\ffYfr::tri:,n::t,
!
rrr\hilt 3, .t*\".*,,., ., "u,\ld.\ *oio
*flu/totg.o-
r CT scan and cardiac monitoring
s$r4cl\ "p"d*i,l
\*$t,"n cu, Ve c"z$eW
urlrrdnr.rr-l t { o',.-,
4("6tAo ,' ai . <-\r . .
t r.''

-\q$q,-g.fi..^taltl; pf , a+@han&d ?ft'

-a$aara qli,ng d.4\rL
+o'1" 4 bhandtt ppt-
E 22
w,rytr,;tr
.+?Ne nallril))UA,
 LeFclrp4\ iosioYl

If distalto commmicating Contralateral Fralysis & snsory loss of tbot or

aflery: medial aspect of
one tiontal lobc. Ifflow in
other antc-rior cerelrral
artcry is inadeqmte:
bilateral frontal infarction.
\{st of lateral hemisphere
and dcepcr structures olthe
frontal, pflrietal, and
temporal lobes; intemal
capsule: basalgmglia.
leg and presis of m; impaired gait, problenrs Stroke: Diagnosis and Treatment
making dccisions, lack of sprntancity. emily
distractecl: slomess of thought; aphasia depends on
involvcd hemisphere: urnary incontincnce:
& aflective disorders
I Diagnostic testing:
Contralateml hemiplegia (face and arnr) and
History & physical (ncurologic examination)
snsry impairmcnt; aphasia, homonymous r CT scans and MRI
hemianopiat altered comciouness (conflsion to rntrtu
€trovd r CT angiography (CTA), magnetic resonance
coma); inabrlity to tum eyes toward paralyzed sidet (conventionalt'
hemiattention; possible acalculia. alexia, finger StgSography (MRA), catheter-based
agnmia. and left-right confusion: vasomotor arteriography, and ultrasonography

Occipital lobe: anterior &
mcdial portion of temporal
lobe
I{omonymous hemianopia and other visul det'ccts
r Emergency treatment using reperfusion
(colorblindness. loss of central vision), visual techniques:
gittrn )o r Tlrrombohtic dnrgs
Loss of all senmry modalities: spontaneou pain;
atseat 11 ,: Catheter-directed mechanical clot disruption

wcpoi{ic
Visual disturhance such as diplopia. dystaxia.
^ R(a&+
last
- &lcrw4co.nvraain e hon^C-

auFkd
--f"fiH+**{rrlrua$
ewQaJ\
ArJcr/tl€n cO,re{0o l,rn,
unald{shrlic'';i'tQ'/ r'ti}

W,ffi
h<xr,"t-N, bo,,,-,.t
adld,t
signs and
r Most
Cerebral Aneurysrhs ia4r* ,r.i

Symptoms lfrt\"J
L^q3e *nr^^r&M5,
4u/4e.Ytll€
or{rrwv_
Ct^
l'^tMit"^*
t ' -;fup':
r,uc g4

. s-\,ur
,. \ {2..vi'i. i:
rtA
Tt,rHl*-"tion orthe pi" ,,,*.ij*.
the CSF-filled subarachnoid space "'".ilffifai
${r\5,rry1Ep;6ttft9
eq*ta\ ttwurcfrJct
'r \\t|lt$r^Eoro€fu r4Ar1ti
hAvCrrqk;tvi,na
oru^^^l small aneurysms iu'e asinrntonuticl *a qFqsr/rndd
-aa-&6t r Large aneurysms may cau,se
"n-"t3$tWd\tr",'ffifr;
, tJ1V. o r Fever and chills, headache, stiff neclq baclg
BVq ta^^rg
Vtu^a4 d;*E'{ r
neurologic deficits, or both. t<v@e f$ ufnfr, urot€rt
abdominal, and extremily pain;, nausea and
vomiting,y.ost{Av\Ra\ l-"o**n-v#i3.*i.ou '.,t[aw,wr*hu,i ul;

.:fl4tto^ o(coea
Other manifestations include signs of menirrgeal OQ
irritation, cranial nerve deficits, stroke s1'ndrome, \tnD
..
r Acutc lymphocwic'meningitis {r\itlVravqc, .. 1',_rJ}l_t',tr
I Acutc punrlent mcningitis rni6a\ b^ci,crla.l fl,rnur-v;i e+J-4t-_,
cerebral edema and increascd ICP, and pituitarv
*t "oi^, r I Bacterial meningitis $S€irto$rfri.ov1\g€g; <arcqf 'u1.
.1NrAru1ct4.{nr r..,,...,, t
,^dlu- .r',..{ag^.... r..i,,r. -,'
+tn), Varh^i"t.is$f r llypertension and cardiac dysrhythmias result from r Pneumococcus daftocod(xlS Oetmor,r,r O e'r'a Cs Vii<,,,ivrrh c i
r Mc.ingococcrrs Ncddia ur&narit&S
cqaarwrdcni*4 massive release of catecholamincs triggcrcd by the
r) | ('J',)- .\\
subzuachnoid h"rnor.hog./lrrnal*oma' .- 9O-g r Yiral_rncningitis sailr. slo ry taicfoioU tart , - .\l
\rtAatwc.,\\
PuFh;, *.^oa* *.v,{..V* ce)toL {lairn hcravi.aL !ii":i'.''',;
"tu$r,rvreo\
PtsL {,\dgrs'ft,, i$E'E "d1u;{\io5-wot'il u;in#:l .,,
c
",
a/doust
ttlytto"c, of +icPr'hru^owlwlic 1

o..ffi^*fu^^"tl"t
?^r+/qrfiemr eXs-r^
cf sce,,rn;
tl"^,ttarr,Uurln l4^sud.,r\-.C€F
"il
ara.oioq6rfuUq lq*
v\D€ttA v\c*L \rvQbwrrvrotOlvr o[Vra,w,troru,t'ttu&
9@vov\2\L4
'potio vio.rc
datrtoctt\c
?4p'€e Brain Tumors
*tl#Trs *flt'?us. Encephalitis &\l&^>cr\ \*ryvo')la rnCNg
a$tlocuilF
*ue$niw I -4r^A ^f+4r
<*
r Infection of the parenchyma of the brain or spinal {. tcP t{F N/ ffitybrain tumors accqrvig -\'lr,'z i 'J,c'$'
r'
!A^,@S trrvrrOnrla6q4,
cord cv(sim Sc
sqvr,t$arnd \araln r Local necrotizing hemorrhage i/^ r Astrccytic (most common primary brain turnor in adults)
t\u+,-ood6
zrusla\qlq,b^^ a7 r Progressive degeneration ofnerve cell bodies 'r/\ \€vr\"ln r Oligodendroglial (59'") tq\ nu\g,ravtli-
?xt,,allr IoW a {-er_ r Prominent edema Nbic Q* i Ependpnomas lining of the
(5-10%): epithelium Pqtrd+-e.,t z.re,zr "le't
fqa{€d
\tA n^^d^41 aig\ai\, r Transmission ventricles and spinal canal wttninn4:l*v t/fawMeano<
n{.r^,\,0\,0$ c detiir\
6,4 r Ingestion, Mosquito, Rabid anirnal r Meningionras (z0oh'S: usually benign
r Types r Primarv Central Nervous Svstcrn Lvmphg!!!4!'lecond
r Viral (herpes sinplex vims, West Nile virus) most common primary brain tumor)
n4\ow\aA
\rca^llu I Metastatic tumof s S€cen! L-al:"4. a:11' ,:'t'r' - |"rw'r(, (-:.
lru^^ti t\cflr@
trpitn' v\^o-\L cor'L.ww" 1ha'r
uf tea r Benign rs, *"lignarrl*ff 1rr"rr:

pon". & cr^ a.- we\,

Brain Tumors: Diagnosis and

Manifestations of Brain Tumors Treatment
.lniera\aari\ lleadache, nausea, vomiting, r Diagnostic testing:
illedema and visual disturbances (e .g., diplopia) I MRI rc*cor$uv\on
*ITI^^-^*t
n:i^ tec Personality and mental changes \geffaoV. -tlnr,vl aX;r\ct
Alterations in sensory turd motor ftrnction (!id61.^tt\
r CT scans + tttn\al iuaeo$tono
r Electroencephalo gr:trl
seizures &'letoP a r Visual field and frrnduscopic examination
ful&u"
ticp
Symptorns of increased I(lP
Focal disturbances in brain ftrnction r
r Include physicd and neurologic exarnin'ations
Treatment:
aBnr.ozrl haivr r Edema r Srrrqen' 4
\c$m*tovr r Disturbances in blood flou'
r lrradi,rtion \Covnlai.r.aho,'r
r'I'urnor infrltration
I Chemothernp/
"3^"tvl1|9!Ledj
r&ion tqa
aQcc^- vreorn.Setd

q.:f14_y_v-r
f vac-4\zws occu.Lon trilis6fp^rlq{i6
hotudnoha\, 24
gwal,tlt^%Mn3 Cell}t[uwt
06flffi*trn
Sae
 jp41 ot-vvv{,. p.W+uiov'+ ail€tr br|daAvral olFaw,4z+vvtm y* icaal ?hoe. (*,- r.izr-, -f"4 (o'f^ao<
hol^rila trl. eeztrfrpaf utfuf
rg4t^r
vu.-a*alro{Ic r
r,,*\schkv) Seizure Disorders Classifications of Seizures
-tu-4i^ rvl Partial seizures FtF 4 agbavA dfsla,.,rgr^'O.
hr^/*,P\r{ _
r Electrical discharge from cerebral cortex neurons r rN,
Simple partial seizure.ott0 hr*rt€flmnt

qq*
Vr^S^,

tjllci{a,," \u.r,r,xr
I
r
Syrnptom of underlying CNS dysfunction
Epilepsy: syndromes of associated seizure types,
r Conrplex partial seizures iu,gulnrod .,&914t.1
r Partial seizures evohing to *f?HthmtEmhd
1Wffilfffi\
ndirnufrsrn
blre.

EEG patterns, examination findings, hereditary -cbai-gizrc'r:

C$nft/
^iro.l
\Aot/.\X-\, patterns, and precipitating fact ors Pcauupsrlh6s/n
t
I
't
9n\ i,rctull*,a
a.to'ffuggt'l
w r :,:.'.":::-1*gy"gx#,&w,e*#:|{i. t
r Neurotransmitter imbalances *
Atonic seizu

-$no^orrug eqrrr; r Types: ^trffi€

!Dra^1;A;
. iaiop.ttr ,;-!t'Ytl
affi;s
- al*.rafio.r.rr +, c-,1-!. l]gp.""g!gg bri-"ry o'
u. c las sifl SPe gt6 f.retzird
I Inadequate or incomplete datzr
*r,,\{ro r11d\ag
- \$hrv)$*.. #o;
..V

a,.ar,lr.tr!.-c.4,{rlrLr

+rro',b't-e- ovrt6n<rrCtiu\ -.\d; e €"-d*,I d.-l.,i'*v>,

Seizures: Diagnosis and Treatment S.tatus Epilepticus
/\J2-
Scite,^r^.1- 'lk'd O
-h^"a ! :-to: qrou*'a''' l-t>uA^-\
r Diagnostic testing: r Continual seizures
Y\- BCe/r^,! .-l* *,.,,.it,q_d€,rs"n .-t{,.rr\ii
s"^. cu\\trr:r:.i
.\tCsUe.w,
r History and neurologic examination l-." C
r MRI Drrll abort &elul\e6, tartAlo ana
r Do not stop spontaneously;;4h -':'Y
. Agot&A/l *lryx!\rz
_ rr^
g r EEG', *k-tt r Many types $V ee5;,r' ^:dJ *1
-(.t. (*,r 1 ."V,.{t,q
nrr*.rndmnRa.l. r Treatrnent: ^^ r If untreated or not stopped can lead to death
l-Hto-tr^' r Identi$ing and treating the underlying cause due to respiratory failure
Irr,lJ{xrlr i0tuttl.tt\rL ql r Antiepileptic / antiseizure drugs r IV diazepam of lorazepam ''*u*r1'-L(i'-;-'
r interact rvith oral contraceptives; sonrc lffcct
"f Oa7^r- hormone function or decrease fcrtilitv; risk for -o9{op ger?,*^.- uCi*;\v1 -l-\-.c-'.-. 6\
congenital abnormalities and other perinatal -{v..ro,.a1x-;.i .*}.^,(.,. Vvl.,
complications

25
 -thal -ttrc +hAtruolls
*tLsanaaqitfutvro,hq{ml zattrr, +. LnGh rioe +oIrea
w$rsll wl

'.4^tss - v
c{ gouis
"uidta8a.lvr,
cr.r: ;qdi^^Pcl^.o'J6
-fx*. fr"raa/strua
uotlt*ua\ar,r,ur
slcvv\ celdP\-'i

3: Pwtiin *cA.ttt- E
alt evtce2"{ i.r$,2-r.atri
2-ua^^
ps(,:
Ut- <.rt

tJ:*t"$+-
Aqann*. a eacr,v Lc lur{hi1

9po$c cta,raolaiarce
Characteristics of REM and Non- vv{\L34,,6vJ,6/t-
aml Stages of Sleep ..6v!."ip
P'eadL ghorc4- 'it REM Sleep eoantA
pavr\rr\ues/'
.

tW^At$ eqc wnw REM sleep "1|&ru^irnclr^ift

n rfftLftr\.. r Ilapid eye movements voit{ l*
Warfnat,,gP I Loss of muscle rnovements J voltage, mx"d

R"th"\d"j" r Vivid dreaming

r ANS changes
"ohr\5. r Increases blood pressurc, heart nte, and Hpintions Deltr(1 3llz)
r Dcreroes cerebral blood flov. and metabolic nte
Non-REM sleep
r Quiet type of sleep J voltage, mixecl Clusters of Srrpprcssed rno€r im11oE+eftf
r Relatively inactive yrt ftrlly regulating brain
lrequency tzpid cye
lnovefrIents
rvith loss ot
muscle lone
ptlae.fti rcslfil
r Irully movable body uigltl's s,luy

| -q!'r L llllftl< hl<,lu Yq/wv\.'rl' I I

tnntoasqepJrc, inhilns teo 4 wilecX t{^o\rilfi'tlvr^^r4d(*mq
?CtC D? eurxha r$agd\4
fam{ gcar loctiOn \Deg
V csftiflof, ranta gul /urctotootic rof
Deyrr\ ottron of ntrt awr\€h{ I tc,jlaViti\ /*rW,| {o ar t ntvrt.
-tlrarugna.ffa^{ +i{",rr"-
ur,rr l"Wdreil q tr.li*arr.d ?Aifung
 ?aregnrrrtas' tt^+
{stunftonr International Classification of Sleep Disorders u ctrl? iagnostic Testing
6 doqr+
v,Et\$tt' Insomnia \+i
"?r,n
ruiaf;leep history
[ae]. gvr,z _as
ld*l4n5inctrildnu,t, Parasomnias tiee.v&,rarr
t-{&t 3'l- -r Sleeo looldiarv-i"
Sleep-related breathing disorders
^4qu+. rWaanne14111<J.4wr^6l\r0,A,hot'
tlrnotTs-ru'/.launtrorA hal
Hypersomnia of central origin not due to circadian rhlthm Y J.-*\, Acttgrapqyget ot^ectr,,e (NaElr
'i 3r
disorder or other canrse of disturbed noctumal sleep
Sleep-related movenent disorders ffil,."@frttrfrau
Isolated symptons, apparently related to normal variants wetrl? t b
and unresolved issues
udi'g
Circadian rhythm sleep disorders
gi4.Jlv
Other sleep disorders
{ff*/'.!t /e"o^^rp*o,
\tdl.,rc\ t /** drc*,aa

Iqvuac
*g6 enia5vt.-Ttb,$^,ld stua :l,u;1 Crr^d b{Jf-e-o*i&i- C
1i - r Circadian Rhvthm Disorders
ur.to \^ow\i?!\:\.
(',e.{ur *quuai:1. J\JldtLA-a4 ilowu^4d- ;-ra-1r-t
;ss€Ls*'\ Y :*^$afg12
\*lv*:"J;wuun2"
^\lw
T -ct -r1r.rr*l.urai \raivryt<
ettoaat* w\ %zrwvierr L4 I ielzryc,{4uru / tU+
fff,mt":qoid,/
"\.t4caruS*p4& ifficulty initiating sleep, diffi tirlry maintaining l)oi$ecilt$t\+:l
loula g^;.Pfa irei r Non-24-Flour Sleep-Wake Syndrome iffirnd-aForlec
, @'qjc,11 sleep, waking up too early, or sleep that is
lalduf
,nj€f{a^}&L r Acute Shifts in the Sleep-Wake Cycle S{$frtro"i""lly ,ioniestorative or poor in quality cheo$tcs4th
*i" {r'}Lb p*itt" ,i . j Adute/transient or Chronic mg*r{.'Alfzrz-artv\AtoV
(-br{r.&c{al iiqr,r,t'-
r Time Zone Change (fet Lag) Syndrome Ds:*-:-- g,mob$lti:prfeuilvu
tic testing
"r Shift Work Sleep- Disorder
Sh"\tu@vr.:0. iW
te car^ri,o
W" (La{.l4 0t,t r(,^^,'i,i,--
-, n. , yrt
{t/.Df-e0ttf,ya1O, rfrvMvrl*4 ilffiil^'
r-Change in Sleep Phase Disorders ?ifiil$ 15, r Education and counseling regarding bettcr sleep habits
b.rll axur,.uc6uDl
fdr,r +q rCl\a^\oe _ gitn
Yi*r, |li!
ioral drerapy airned at changing naladaptive sleep \'1e"{i$fi,tL,lwali
,114*Y'*,;
{r\rt.lvi%;n" t ti+"it "
ious use of pharrnacologic interventions
tr,&p.'"r
,*Ig
[,iiyl

27
 *etllmnrtli- st€trp -t*rp*o{ thqt iNauuu{, EcecAte lZr,tirue
A:,Qe'f!:%,Oe'tuegeD n'oqunvrau ofzp raani$;Jrh ovt
gLV€?'- fl+ p6 wyYy 4 uff4 c{nrrtr,\ wuwtte /,nw.aduy1
ufaLe ug\n rmota(\\
C fleruur,4rn ve6 , Se\rft"
C@yq(q,pp'4
wouqurl'ovr h4
koclnmn q aliu '#,du*/
atu\/a*vyuz/gac
Narcolepsy
\rysevsar
vlusc,lr, r Daytime sleep attacks, cataplexy, hallucinations at
titalaytarb the onset of sleep, and sleep paralysis
r Abnormality in REM sleep regulation
Characterized by the occuffence of REM sleep at
Vtalluar,ra sleep onset or within 10-15 min of sleep onset .9f9rl
r Treatmenr, aatiqb..,^,/1:r\ri:.Vilrrfr'lt- h^*tqW
@ ovr,rf4.Vq
rstimurantmedicatioll.Sfftfiif;ilp
I Tricyclic
I ncyclrc anudepressant"
antidepressants o.-Ar,r {rri,I o,.,!",t.'rluhur$.
r^Wt rrjnrii *^.,.-,,
ffi
r Non-pharmacologic: i ^,rati, )
,
A{td . S.h..t.l.d pg,ention of steep deprivation, regular
'WAU Vg "hor.."pu,
slep and wake tima, stimulating n'ork envircnmeng avoidance
.: I ofshiftwork

pu.\red Pkq
d
cra,tfhW SLazornt€6
'*t;4atd64*
ttatoeunft\r,^b d, +!
\*Z lt wuvt'toP-,tu\
w\yb e
re3:li:M
Perchtive 4a'*tt-, \eotr -V
^e,Ca^aI an,//
{i,yrou ol
s\xt er Sleep Disorders
Manifestations of Sleep Apnea 3t99+N t{atd tqqe ffi ieiolg-'d^rsr\A\
ia . ut lor 4^tnvi., rv*td,cal$J
\eg gryd^['u{
r Oia$rrhc gAlald
Noisy snoring otirL d'llgrn4 P \ r Motor Sleep Disorders tr"',V u/c savz'no$
r Insomnia atkrr.. ,"1,r'rodia i@\f'seriodic limb movement disorder 'lrylgr- A
r Abnormal movements during sleep ,PfgD adrvil
I Morning headaches -- 0cc\r9€ ;.n., r Restless legs syndrome

I Excessive daytime sleepiness TJEEM /o^ltr

fl.lt ad hd,{i.1
r Cognitive and personality changes ,,,,,,
r Nightmare.t }*ri l" '{v.{IB 30l"
a* wd7urot wotl-
r Sexual impotence
u^*,t
rYrnrr
Sleepwalking. :Tl,frl "9
*-*n/+nnWrt'116^
r Systemic hlpertension r Sleep terrors rrtutnt+a{{F*,^
I
.\qvhuds
111$l.lp
I 39, se",e.*tq^ drl V{.
Pulmonary hypertension cor pulmonale ,iu; r Teeth grinding :^:oodhl wallcirrq g;rlJ.^4*r
r Polycythemia
',|''ryP-
,*g[u;;;;1.,,.,,..i.; e s\\f

rruny,lru.td

SWV WV-ae.j $/dru.,rrr+.

fC&-f ai ef t &rJ.lrurrn : I .?reowrryrl;lri;
AN5 ac{ivihoq -ia'tirru;,ri ,r:rri
28
r
13ryy. i1qr..*- ",,r',nid.-t,,.t,
rtaot,3i,v UpX\r
t o$^!v\,avi rtn. ulu\lr'iv; - J$gad l{9 cver'tUr
 Question
Obesity rnost likely will be the cause of
Disorders of Thought, Mood,
". Central apnea and Memory
G. )Obstmctive aonea
\/l

.. Teeth grinding
a. Sleep walking

'(jr\lt :y
C - 1u if, . /,'r
11
rytdttc
t uf
iv{,ql:t\ed (k' tir.,\ - -1, a.\.'
Schools of Thought on Mental
:$\.I% {"%ov Wt'aA' ryd et*\!-
dt'ud.)n\tft e( *u-faLi-t0.oa-o'l
A"n;;rtJ,,;,*;, ,
Heredity in Mental Illness
Disease
r Biologic psychiatry r Complex influences of genetic and
r Mental disorders are due to anatomic, environmental factors on neural
developmental, and functional disorders of the development and function
brain r
TqWx^^\ Nurture versus nature
r Psychosocial psychiatry
r
w',uad!,Lotw)w Genetic vulnerability and environmental
.
*l'*{r-r.t i
r Mental disorders are due to impaired
psychological development, a consequence of
influences play significant roles in the
fp3.-tlw,:oaol development of mental illness.
'hsrvi' ;;r *"rirrg, or environmental stress
uJJai,Jhl'.vk^ ";ifi r Other factors are involved.

29
 -b"r,lrt Ldye. . Koppwa1W . 4gCFatl rre.
' concevttYahoA vrnaHtt

,lff; h: o_YWp p orqa"sl*}v (euol"nn

^
#, s€[S.ffirhk;,,-r,r th. i,ui,, Question
ttlott o'ral unnd,ul ahr r Cortex r Which of the lobes of the brain has a maior
ttttE?rr4alrrrvr
.
.

r Thalamus role in decision making?

l,^,lhil4c \attvdaon
I Prefrontal cortex
l*.rvtgfrrraaay r-^r'el
tt^h{!/i$tpbvk?hr
v*rani vilt oI r-rt r,r a"l
r Frontal lobe @
r
r Temporal lobe Temporal
wnla..r*trcruct*e
.lfinck ' ' i
'r Parietal lobe r Parietal
r Occipital lobe r Occipital
r Limbic association area
r Medulla
r Prefrontal association area

fu.M'fix, Z \ eplarr \ O"suro* 4161 gQrl o.d

0r

^rY 'awri-kz1vtq
\r.ha€a' \ @t^€tv\ teo"na,1'ragr
\
""\{hrfi?d cv{+
t'rv\ \wr.*" \ffi;
{}l\rrinfior'r, scm
COotrtt;1l,,a1a qqfi. +Wrgolfpanarrrdt;gz
tcliad.-\q4a, Neuromediators
*rcfi\C.".too^O
Aui,rahandwri:*;w
i
w ?eo€Lc\,r\i0{}:
paratun nioqtA kr
qr.*ic* r input of sensory information and the processing of this sv r. Synthesis of a transmitter substance
infornation into meaning z. Storage and release of thc transmitter
44fhot r h^flucin'atiorrs W du'*13't \ad(
t\rrr7\q Relense vs. Ictal
r(! et(u^\^,Je, :. Binding of the transmitter to receptors on the
Visual, auditory, olfactory, or tactite \&A4- postswaptic membrane
n"1t^nqt^6
Delusions: +. 'l'ra.nsmitter removal from the synaptic cleft
Pr.rli.O
r false beliefand the persistent, unshakable Acetylcholine, dopamine, epinephrine,
norepinephrine, serotonin, garnma- aminobutyric
wryt Delusions of persecution, influencc, ill healttr, gran.l",rf,U' acid (GABA), glutamate, glycine, and aspartate
corifru,trn
comvr.r,rf
poverty., possession, etc. W eeanc\_lui : ?^rn/,^!,
r:o.gwar5: {A"ib ' t*!\d"-
l,\lD4r
w Toeaealtir^ : qlw grud\^n^ ;le\.u'rtonl r,S.c). u.l rroic't'1
*\o(0 \fIw\ -1r )..lwr,\+ tt :.
'Att :A'Ar).hn
rd,utrff n
&0,-,r,rl qCze,rU-r,rf.u
+N^^^ ,

Orlh*ur.rPU5.u".l Wt *t3' 30
 $,pa,ltc trypi $lfttnll gscol rr a <r n',4 ffA'ine..n1
Wtrtl^^1F 4comp*t{ ?a.tt4
othOn Jer&za\ orkatrn*',;(-
Emergence of Psychotropic Medications in vrratn Schizoo hrenia
wwoUeg u*ircaV g1p,1a$clr6 I rit",ruE v,i r*r't\rtl.
Alter neurotransmitter or receptor properties of the brarn *{ rChronic, debilitating psychotic disorder that
Antipsvchotic agents used to treat schizophrenia
r Tyyricalantilxychotics: involves the disconnection between thought and
r Blek dopmine receptors language
r Phenothiazineg Butgophenmes,'I}iqmthoes
r Atypical antipcychotics i Affects the thinking, feeling, perceiving, behaving,
r More refined dopmine blockade action cornbined with blekade of experiencing the environmenl
*aotonin ieceptors
r Mqe effective in t eating rhe negative slnrptoms of schizophrenia od r, Onset between l7 and 25 years
produce fewer ertrapwamidal effects or,kfioe
Antidepressants: Men and women seem to be affected equally.
-t!e-YYU{r9
r Increasing the rctiviq of norepinephrine ancl serctonin at
postsyraptic membrure receptos $-a5
r First-degree relatives of a person with
r Monomine oxidce (MAO) inhibitos schizophrenia have a l0-fold greater prevalence of
r Tricyclic utideprcssants
Rwn\rs J5- 1e the illness.
r Serctonin reuptake inhibitor (SRIs)
r Novel oratypical antidepressants.
gcrng trrlr w\r*r-76geing l2'4c\naCpz. w6VU in{tMorrzal i
't\Y at ,*krrthna\ ddai6 ' ,,,

P\,uaiou, ta€rraarov Manifestations of Schizophrenia Schizophrenia: Diagnosis &Treatment

u4 ov\a'rr-$-.e
prlLt{ohc \r n ytltrr. : f€*ro fLvr^L Wi txl-e 2 or more of thefollowing symptoms, lasting for the
dAll,utiv\n\ 4.i. --
W4^l^1^
J Pbsiiive synipioms oer. d{rrriqiort/hrr' maiority of I month:
V!|CCA r Incornprehensible speech ri'Et{r, a\ w rndA |id\tuthctl r Delusions, Flallucinations, Disorganized speech, Grcss\
disorganized or catatonic behavior, Negative slmptoms
r Delusions and Hallucinations I or more areas of functioning must be significantly
r Catatonicbehavior yo44dcd.^4;'*\d 0b64ta^i$^b impaired, and continuous signs of the disturbance must
r Enhancementorabluntingofthesenses -T persist for at least 6 months.
r Sensory overload due to loss ofthe ability to screen Treatment:
erternal sensory stimuli r Goals:
- r Initially, goal is primcily to reduce agitation ind risk of physical hamr
{trEnrfa,acncq 1g Negative symptoms I lndtrcc a rernissior
sFalev€^ { \'1fr,&-tr r Absence of normal social and interpersonal behaviors I Prettnt areorrtence
r Affective flattening, Apathy, Anhcdonia, Alogia, r Restore beharioral, cognitive, and psychowial fmction
Avolition, Blunted response to pain
- r Phmrcotheralry and psychosocial inrerentions
fu"W\ o\i&*€d
Ur^^&d ceefa rr bp^\A e3

3l
 fr{@t g'4o'f, &olesE E hqlorz. aqan'a.laoy
A:rfaan ndet 4 5.1b. xtoJarlr..I in zos awipl % locaryiOt
"Sn
Pio{r t A a4z
d4erlor't o19o5.lc
;r'vt gS'41" a*tlo.:r)
uap ti-x::,-)a^) Mood Disorders ?o\4ve Classification of Major Depressiof, u, 6:nf,e * l\
. ttu.at4gcvrrh,_ o\4 6r{$Ja^
tw*rl7...rrir c,,qV\Lgt6
l(o
Fft.lisz>"rt't)/' IDepression: a mental state characterized by a c.9- r Unipolar rA

foewnA ^v. ;pessimistic sense of inadequacy and a despondent

iJ r Characterized by a persistent unpleasant mood 6 plaloSc{a'hagr
Ah^,{rw,31,.) .*i^ lack of activity b\rn6Al.\\dr\do6*\^dt
-w>ft r Mania: characterized by exremely elevated mood, / p \rc t\.o4cod\gpuot
en€rglr and unusual thought patterns e oatabn\c$rr\r
r Affective disorders anch.pe6 t'" \f€ataA5
r Affect approximately 2lo/o of the population arhu 6uL5 ap
r Women affected twice as often as nren *cAff?t*as
t 2040o/o of adolescents who present with maior v\i\rdol? kqwt*iV {hl,ilrE
ueigarou "
depression develop bipolar disorder rvithin five 1'ears. ffid/
' -r lvl61i1s-'qzug.-friv-
v:l
-eW'af| / -',-"'.-
rn^a,atA Vere,1 o*r1ctrv1
*ob/tragq lrixn*rvtl \Ydrat?i\^\
,c1\<"oec+ o\ Qtc+tro'/\ \qaAv%
: \4,il,\< LVt\,vr!
f raboa-puwyir 4,'4ach,rr\ a{ avuqgdat\a dvtPivg dq@-8\6^
Depressive Disorders:
tecontirrug
+o L -
Characteristics of Depression
tZ manths a,{rcr cWer,t qygaivG ' atlcpaliOn S\rel Diagnosis and Treatment
selr,?.€ urUrrn TA r Simultaneous presence of five or more of the
oI\ r th\l
rYvr\edal6, +h\l I r Anhedonia (inability to experience pleasure) symptoms during a 2-week period.
bn# lrD vrm**,,{
vtocm^A @ r Differentiated from grief reactions, medic*ion side
-{hef{d"ru.--+;;e/= r Feelings of worthlessness or excessive guilt effects, nnd sequclae of medical illnesses
\ -J qna e.\,ad r Decreased concentration r Bipolar disorder is diagnosed on the basis of the
I Psychomotor agitation or retardation pattern of occurrence of manic, hypomanic, and
depressed episodes.
$UlUr: si {;.; ttr.ott nia or hypersomnia r Treatment:
t€,td)!oi,^ayr. . qnAJh\r. r Antidepressant dnrgs
<rEx,.,r!,ra\r .,r,,.?)!
r Change in weight or appetite r Electroconl'ulsive ther:rpy
r r Lithium
Thoughts of death or suicidal ideation
r Anticonvulszurts
6E^yxor vh r Psychotherapy
-$"d bilolr

n\nFq5
btwn
32
 rrlUee{ac$,rurtrea S pnnnrq Uev?pr/€, qsrt *tV J .\Aa?vi.:.: vaw
J|ivf.i2rr,,11,1.{ \f, \t.-?Ar:W:
"nY\:gE tmuc{+ *ha,n arrottue€ee€ovisesto€e
U\ eavl'{. €\Evtt -U eta$@oz+d'C.ee?ov\€a
glaaan.*Al r)*ttzo
aigeig; criril
-t!tt*a.Rd
ffie|W-. ita*rirfrr<ce+ 'itbov:tircolt
^Vaao
+ avu^15

+trarntr,rS
F{fi, f >,r : ft\tlAtlrvrt"<, !J41%qAOV- /.e$Lr$a r tpotrta\ -{.u^F9o\
aq',vr,L\{* Cacun&U -la Vo w Ws st- $nv$\ de -Vo V-t ti& \n dru rr !
subtedfue wu,afl, Types of Anxiety D tu*iqiron Utncta Dementia
lqtFr4 ^*A r Impairment
W )Faa.,tJc, iY"g&istsr#f of short- and long-term memory, associated
with abstract thinking, impaired judgrnent, other higher
-a1a4
,PkF4rue wrr.r,rRl r Generalized anxiety disorder
r
cortical functions, or personality change
(laused by any disorder that permanently damages large
echvrhon sJ*L
.aAcarl"g r Obsessive-compulsive disorder association areas serving memory and learning
{apg otSocial r Diagnosis
W+\t6r1&ui c4r,o4 anxiety disorder r Asscsment
."tpi{otrn,'i[ri'ji
ffiffiffi[H;xfi*e I Hisror!
ae1"r,ra"th"
+*rrLi
'rNn&A h oua'ri!,
btl+{rffisgv'tz.z m r
r
r
Complete ph,vsical
Cognition
Functiolal status
6qxaLiyA r Iabontory and imaging studies
ir+IlrtrylAc4drz- \&
a$ry \.2 UruantUO\rVt
vtlradr.lneio\

;ne\dia,tclt^, e colW
F.++.Age Ar0
Waruln Orc .\tnan

gSdott,re sh&g
*p;,:n***^mffi
&sKEuruoathologic
.tosagrg*
!t\\\
pranambea
l4rri4\
*)od e Hidir.\
*
fi*:'\." Stages of Alzheimer Disease
['{d.Jffi$trffi;:,l':fi ,:p"Fd
r Short-tem memory loss
ualgairri {0. r Mild changs in 1resonditl'
4trarrc str*er, ca neurotransmitter changes {0i2h44L
I Randomly forget imlrcrtant and unimlxrtant derails
| -\-2 W t?aq,tteit*^ns ;t
.*t^ r$e 1ro lqnin ;.,1. Cortical atrophy and loss of neurons, particularly in $r n--' r Moderate stage
-*+ <Aruntion z
the parietal and temporal lobes
ftzoU;*rl
t r Global imlziment of cognitire functioning
I Chmga in higher cortical functioning nccded for language, slnrial
Ventricular enlargement (i.e., hydrocephalus) relationships, and pmblen solving; disorienation, lack of insight,
from the loss of brain tissue I kuow y1,.9n {lLi and inabilig'io c"iy o.rt th. ofclaily lir.iig, extrerne
{alruptttt., j ".tiities
tt'r Histology
-\ur,rjotr<rrd

'rycuAcat arapl..r -7 fuq1rl apoa){A r Sever-e Alzheimer disease is the last stage of thc disease.
trtcr+ drurrqyr,
1 r Neuritic (senile) plaques: bAPP :ovrrelkros Ya1\n l^€\ 'i\Ar.
@
t,,,i, v*,.Vyrrql lnss of abili5 to resJnnd to the envirurmcnt

batrop.^1
hr Eita.-n

+ ye,,rlFir.^r.*.
i;Xd;i jffi
o i,']c
:.#q*nr*gn*
["'i^q,**t
,,ffi
iA gaee.,^.^t , ,r[ft*.
'l r
r
Require toral carc
lledridderr

-firofta[rpncr
9 ji)l Denth can occur as a result ofconrplications related to
chronic debilitation.

Cu^dmg of &f*a."t n)\reeve {Cr{[,rirvrt:,

VAtqg fla1..r+
33
 0t ruqu 9paxne
3e[ ivr sq/€C Vt€ctr\Anz
e-%1, &wrrrrho'
esE*fr..
Diagnosis and Treatment
\At(' K*'**Ut/'*gVnS/rtlsqfr #fs-Hffi ffi/o*;t,r^^*/
S;iHHfi; r f)ifferential Diagnosis in Alzheimer Algorithm:
d/".*ru.,.a
li*"ortsvl ffi,f;r:ffi
$ r Mini-Mental Stare Exmination, Blessed Dementia Tesg or similar . rI lffi*il,"T;'T:mentia ffi;J**,i' *
.trontotemporall)ementia -ilftnirrlilue-.Qic$A c4rrd
Pa$or-1
tnQtittue- geotoul
mental starus test iwgi @h4\fi.,1 ".,. r Disease g\&n\s
Creutzfeldt-Jakob W r(bWrrcaftarl
r No tlisturbmce in consciousness
r Onset 40-90 veas of age, rnost often ) 65 yeas
vro,"l-r
r S/ernicke-Korsakoff "eakgla'es.
syndrome 6Crturv-eo\. .ra:taltt
.^
. -lt aDCON
r Absence of systemic orbnin disordes
Vugu\
dcrauiclzr- Vo*slr+r*
ctbPenia;ll{\
e\!Fev\iaz?rr\
r Bruin imaging, CT, or MRI trr exclude other diseroes l- tVernicke
:rnicke disease
disease c\crfi
a /wcav,aerisa(
r Metabolic screening for other causs of dementie (vitanin Bl2 {?s Cjttfr Veakness,
weakness- Parall
Paralysis, Nystagmus, A,"ffi8ff:ffii s'6.1aiat
deficiency, th1rcid dysfrmction, elatrclyte imbalance, etc.) +A*rn Peripheral neuropathy, Unsteady gait, Diplopia
r Treatment: it ,v* l- r Deficiency of thiamine (interferes *itt proa"ticion of { 'L/ut^<ta:ti4
4_,*v
r Slow the pmgression (cholinesterue inhibitom)
r Contml deprcssion, agitation, or sleep disordes t; :aJZ glucose)
1
r Huntington Disease
{trxa}a,ta ladoo,."f
*r.lott,.rtltara*\
t...|[QAl" .L \,rtBtz
*{goh\c
-qfl
!ha€€c. o{-"ttoct
ffii"roffi
e(rJ€ t2€ iq/tya{ g_nr.ont
I'le
^t l.\)r.h*h"y,r

ffiiw\w\dile \o*l^^to4 mruU"lea

ififfi.?#Y*
Disorders of the Eyelid
Veakness:
r Ptosis a
',,61-tftrts?qi6qF
r V eakrrss .f rh" t.or muscle
r tTnopposed rction of the orbicrrlatis oculi
I)isorders of Visual Functron r Wealmess of orbicularis oculi causes an open eyelid
Inflammation
r tslepharitis
r Seborrheic: csociated q'ith seborrhe (dandruff) of rhc scalp or
brou's
r Saphvlococcal ble pharitis: ulcemtive leions
r flordeolum (Sry*e): affects the sebaceous glands of the
cyelid
r Chalazion: chronic inflanrnatory granuloma of rr
meibomian gland
r May follou'an inremal hordeolum

34
 'figotp€s c a:(.l.aAn1 -wdqrvee
bHe {qqc
\erk {rnr Dry Eyes
taggtttal Question
seadtoil
I Tear fikn protects and hydrates the surface r Which of the following disorders is not an
ofthe eye. inflammatory disease?
r Deterioration/disruption of film r Blepharitis
r Aging
r Loss of reflex lacrimal gland secretion
r Flordeolum
r Contact lenses r Chalrrzion
- cd'uhe\ntr $eaViub of ta.ra&ae v^ilsrta
, ,r:Tfl"J"?ndrome ffig$
f"w\r^i,ti/afr4ut
@ W^DtAacd *oura ucVilwl6paS
r Artificial tears, plug lacrimal puncta, ointments - ^Cho,^

*,lWL ot*'.,rror
4 -, iq{r-r* o ir
p4trueA
dgu"o{irflawrr t bnai vt
aUaale
Disorders of the Coniunctiva r*,ffi ffi ffi d*'{f.f,""8o}h$"F
jrer-ftrurrflOri 1.S" t igft {f r orfihaacna\ okra
r Coniunctivitis Corneal trauma
*chrttn r
r Infectious coniunctivitis Corneal edema
iltt!nd,oa,a r Bacterial coniunctivitis r Keratitis
Schs&ch,ii.rr1 r Viral coniunctivitis
r Bacterial keratitis
r Chlamydial conjunctivitis
*x onirbrid:ernl r Ophthahnia neonatorum r flerpes simplex keratitis
avh rjrlarqld,Hl r Allergic conjunclivitis r Acanthamoeba keratitis
u a\\eugp Wr**q'eo6ov6i arlee.lu r Abnormal corneal deposits
E-tolq \5 e vl^.U,r"td,, \tnca6,erxVftui -al1^$t
pturrhS
r Arcus senilis
o'(trrtlt\t(. {4t.nq,,'A^.ienpn!BVt
t39

35
 Pupillary Reflex Control of Intraocular Pressure
iarz.^ g11e|6pfog
,'-\
bAolfiil-b Jnnaf : *|zDn dl4dac (xa We-
iu *.Jtloc -+aU{{atntralr- 2\$.f qtauans
cN Controls the size of the pupil .
r The aqueous humor
4 e6dr
.rr-r Controlled by the autonomic nervous system r Serves to maintain the intraocular pressure
s\.du'le r 'Ihe parasvmpathetic nervous systcm controls pupillary ?f.t:ulr r Provides for the nutritive needs of the lens
constriction. -hxr tr,Prlt posterior cornea
CNe hur.nop
r Ttre synrpathetic nervous systcrn controls pupillary
dilation. lnq I Mediates the exchange of respiratory gases
F€'kno[h r Contains a low concentration of protein and
Alterations
r l)anage to CN III high concentrations of ascorbic acid, glucose,
r Opiate usage and amino acids
r Miotic drugs

\dCfzae< tv*uoocuLng pe96qpq .-p op\ciec o^Ttrn3 -vviq,r+ufiep t+s

\pnves\sue
+cper,art 4rg{tlrL oos&Q\oe L\q^v^Ve@
oco.rgoinS
lassifications of

A+t1r.s' -lpilarent/
.- opn *w$e Definition r Angle-closure (narrow-angle) vs.
open-angle (wide-angle)
r An optic neuropathy characterized by optic disk r l)cpends on locntion, circulation,
cupping and visual field loss
- Antu 6ae(. and rcsorption
A$A\,c Causes r Congenital vs. acquired
r An increase in intraocular pressure that results condition
SPt\d,l ontcoi\\oYl from abnormalities in the balance between r Primary vs. secondary disorder
r Prinrnry: no cvidcncc of;rrccxisting
covttgtlrtr/irzd aqueous production and outflow oculitr or systcmic discrrse
outfuar.l r Most common cause is an interference with r Secontlnry: rcsults frorn
aqueous outflow from the anterior chamber, infl arumatory proccsscs affecting
rather than overproduction of aqueous humor thc eyc, tunlors, or blood cells of
traurnzr-produccd hcmorrhage

36
 a\?dtln4 -r'rt / linsanrd u'?^ata
\leot d {*rcn^rtra a1geo3r*alc\
Question Disorders of Refraction
vtaon bdht t Qdinq,
.ift,t:Ct & ,?dt Hyperopia or farsighteclness
Which of the following is known to affect the
l*e cro9- r The anterior-posterior dimension of
,.ry
pupl ex? 'gryrrrlqn t ag q the ey eball is too shortl the imagc is ir
tilold, 1t,.tilg p.ryuaiw*o { il{,,.ritr nt: focuscd postcrior to (behind) the
I Damage to CN II \tat*b retina

r Infection ofthe uveal tract r Myopia or nearsightedness

r 'Ihe nnterior-posterior dimension of
r Increase in intraocular pressure the eyeball is too long; the focus
point for an infinitelv distant targct
is anterior to thc retinn .'}ilftr-
ca$ sac c,\se S t1noVans dc
crccovnodak rrtari-otijeaC Wt
S x<- oUlptA+ ih^d avc d'rci6tr\
ttta\urlou -Lr: t-rraik.rrrp a\a(*F,

E W qodlq - avrqv\e,ra\ rngfr roecowuafucPlO

vHon Lre=fgwsslg'E
*+g€d(d E qryep\
Cataract Retinitis Pigmentosa
Aqe.{dowrrmtr Lens opacity that interferes with the transmission
,,ndnVolic i$unos of light to the retina Slow degenerative changes in the retinal
trolrtel€c Cause of cataracts are multifactorial. photoreceptors
stbhvu/da/g txyrudol r llffects of aging, genctic influences, environmcntnl and Autosomal and sex-linked forms
+*\iv r
metabolic influences, drugs, and iniury
l)iabctes
r .16 RP gencs
I Night blindness
r l,ong-terru exposure to sunlight
r lleary smoking I Bilateral symmetric loss of mid-peripheral fields
r f)evelopmental dcfect I Visual field defects gradually increase both
r liecondary to trauma or discases centrally and peripherally.
Treatment: Cone photoreceptor cells are also affected, and day
r Surgerv is tlre onlv treatment for corrccting c?rtiuact-
rtfated lrslon loss (-ntraoculirr lcns inrplantation) vision and central visual acuity are compromised.

37
\ec{kdv{ a[ \agutev6m:
trocrrrnc a,^l

tadna @a a+lcr$Mb4ar_attaapE rn
op?.+
scBr<
;ffitr" ffife#dft4K..'iffi ^a$66 ^. . D i iBEiic-REiifrd"riltEv
",-btl$?StEfrfffifiv
*'
,^ilffi *"
"'ffi ,""o'* em#*fi,r*:nw
r Confrnecl to the rctina
&ruage : Engorgernent of the retiral
veins, thickening of the [zetlvrst[ r:al''J'z >
trcaralid r Central retinal artery occlusion capill,ary enckrtheliel bcernent
VUmdfirw r Central retinal vein occlusion
membmne, and development of
capilhry micrcaneurysms
\t.\, uem, r Macular ederna
Proliferative
r Fonnation of nev,, fragile blood
vesscls
r Bleed cuily
r lletinal detaclmrent

gch$atkdiug +om rllr$ gchirdit e

W$c+ou-e )roou"a44:b Drr.trtmkoca,tg

me"^"
{"^dWW
ffi'&HAtr}it "Xnffi B'ffi .F"?';t"i8fr**'
Ovnww in eklaU'1 Tugu\atlovt
turqadl4\ e^n&,t, Separation of the neurosensory retina from
epithelium
r Degenerative'changes in the
qh;cnwlolw^n r Biudative,'I'rution, Rhegmatogenous central portion of the retina
Risk factors:
(macula) -+ loss of centralvision
r Advancing age r Risk factors:
r Myopia r life)fenrrilc sex, white racc, iurtl
Mnnifestations tn ?e,,!sk cigarcttc smo kin g. I ncreasing
r
r
Painless rision changcs
Flashing lights or
& evidence suggests that genctic
fnctors
sparks folloved by Dru\Snm
small floatem or slmts in (ey.rrdJ/'; Age-related macular degeneration
the field of visiorr r l)ry forn: Atrophic, noncxudttive
r ashadou.ordrk r Wet fornr: I,lxudative
curtain prcgressing
acrcss the r.isual field

38
 D5 qc.
a^erp cor^hgdu4
I n4{z
Disorders of the Optic Pathways

Intermption of the visual pathway due to

vascular lesions, trauma, and tumors
r Anopia: blindness in one eye
ro,[d cf["et Bv'
r Flemianopia: half of the visual field for one eye
CtqL O{r{e qn
is lost
c{ntra\ e @^p r Quadrantanopia quarter the visual field is lost
for one eye is lost
r Heteronymous hemianopia: loss of different
half-fields in the trvo eyes

Bvpcu\ara lo,alior, if
?givrra1.4 .Jrrat:VtL.
'vcaAehJ_ [..1" (ov*ion ef ,rs,.rr.i '[ccl. isl.rr.lcci
ic-*,',1,
.v\ Dcu[rr\;,, e
'rb'r9ry;. pisorders VT Extraocular Eye Muscles and Their
u{+{ftq1lncu } ' ,I ,.yIUUIULTU of Visual
YIUU4I Cortex
VVTLL
al \ul-At\rl,;!
Innervation
viarr\ aau,,oda
,o^*od
tcru^ao\t .rro v\ab\
-tro v\€llo
r Cortical blindness r Innervated by three cranial nerves
oseOC(a,hol i-oefr r Bilateral loss of the entire primary visual cortex r The abducens nerve (CN VI) innervates the
-$ql(6\^&g.ow.dg lateral rectus.
,rt\"hclr Wt*^[1{ r Visual agnosia
oa^s\ Co\A;.4^f \ r Extensive damage to the visual association
r The trochlear nerve (CN IV) innervates the
rr\qsG^J,l.d. cortex that surrounds an intact primary visual superior oblique.
cortex, resulting in a loss of the learned I The oculomotor nerr,-e (CN III) innervates the
et remaining four muscles.
t!\^oapg{ meaningfulness of visual images
€e(. UAI-
{r\t'qas519
t

39
940Cl0lC ctl€ uls/emq'Zrt: s^DDevl

f,c&vq cadqa*a.wwgatuuts .hcdkorn ef.Iaorr /-K^r- €4t'vU- \rr.rtlL{$po pzt\na-S '7 a'r^4'
_$dtr4uic)rrrl A
lt$o$arl&,-fto-Wten rM,oE€.cnvrlvrror^ t!\ 7ev4eik tre.ft
{\,tt 5 \^afit/b 93ou8atdo^ sD^-F
fbc&^ Eye Movement1ffifiilm/d;, Disorders of Eye Moveme"t f #, rn a4o(q-p.*K X
dfr^/tg.Ag r4yeg *l^^thorn {n {acd\-et\d r.r.. 6/'^
-to vrq,o tVo{',On ^^ r ,'{{)
i sm ooth purs uit m ovem ents .[e%\en@,^,touew.trr\s r Strabismus /+4ui uttitnl '':.i$,
Vttsd orryfroncr r Any abnormality
Uun o[ rl4iov\r r- saccadic movement, )"@ +*\1.^ of eye
r1.r l. l

\*ila\ ardc'r\M I Optic tremor oqcd ?uaqrq ?ry coordination or

dvotrrrd*^* * r
\wdacNbq&. pn*ot"
Vergence movement. Jis{.;4i&E;Nh"\r
alignment that

',^;!1 /sd.=
results in loss of
$dd!A 'i\Et\40^^"(
oweaLln-ac\^n'?
{oV}tr{ binocular vision
eaL[^ r Paralytic
0lcnour rrrM ?\€tF d*tSu,,ill\, strabismus
-{(arq$\^lA\i{'q 6{^/,^t
r,t-+gghcal o{)24",
r Nonparalytic
strabismus

Quest 10 NS?

I tt

40