CENTRAL NERVOUS SYSTEM-theoryCOMA:
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The reticular activating system extends from upper brainstem-pons, mid-brain and thalamus.There is a connectionto the cerebral cortex, but for the level of consciousness,the degree of wakefulness is related to themass of functioning cortex which is affected.The degree of decrease in alertness depends on the acuteness of onset.
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Herniation- Tentorial which affects III rd cranial nerve-Herniation of cerebellar tonsils through the foramenmagnum
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Causes-Hypoxia,hypoglycemia,ischemia,hyponatremia,hyperosmolarity,Hypercapnia,hepatic failure,renal failure,hyperthermia,hypothermia,Drugs-Barbiturate,Morphine and alcohol.Infection- Encephalitis, Meningitis,Gram negativesepticemia.Hemorrhage- into basal ganglia, thalamus,pontine,cerebellar.Basilar artery thrombosis.
Head injury.
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History - Drugs,Alcohol,Trauma,cardiac arrest,precedingneurologic symptoms,history of liver,kidney or lungdisease.
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Exam
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TPR BP
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Effects of alcoholism
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Evidence of internal hemorrhage
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MI
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GN Septicemia.
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Addison’s disease.
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Fundus exam –useful in sub-arachnoidhemorrhage,hypertensive encephalopathy and othercauses of increased intra-cranial tension.
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CNS- 1)The nature of respiration and thespontaneous movements are observed withoutdisturbing the patient.2) Decorticate rigidity- flexion and supination of upperlimb and extension of lower limb.3) Decerebrate rigidity- evidence of mid-brain damage-extension of upper and lower limbs.4) Focal neurologic deficit.5)Elicited movements and level of arousal.
6) Brain stem reflexes-Pupils and conjugate eyemovement.
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Investigations- CT
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MRI
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CSF
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Blood – serum electrolytes,Blood sugar,Blood ureanitrogen,Liver function tests.
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Emergency treatment-1) Correct BP, Blood sugar level,O
2
,CO
2
, Hypo/ hyper-thermiaimmediately.2) Airway.3)I.V Access- Glucose,vitamin B
1.
PARKINSONISM
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Incidence -Common in middle/late life, graduallyprogressive and prolonged course. 1-2 per 1000, I per 100in patient > 65 yrs M=F.
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Mechanism- Dopamine and acetyl choline imbalance inthe basal ganglia,they modulate the thalamus which isnormally inhibited by GABA.
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