Neurological Conditions

Motor Systems
Pyramidal System
 CST/CBT

Extrapyramidal System
 All the other subcortical parts of brain that influence motor activity
 BG (Lenticulostriate), Diencephalon, MB

Basal Ganglia
 Corpus Striatum – motor system
 Amygdala – limbic system
 Claustrum – unknown

Corpus Striatum
Corpus Striatum
Caudate Nucleus Lentiform N
Striatum -> Putamen Globus Pallidus
Recurrent

Direct Pathway vs Indirect Pathway

Direct Pathway
→ → →
At rest: 𝐺𝑃𝐼 + 𝑆𝑁𝑝𝑟 𝑖𝑛ℎ𝑖𝑏𝑖𝑡𝑠 𝑇ℎ𝑎𝑙𝑎𝑚𝑢𝑠
𝑑𝑜𝑒𝑠 𝑛𝑜𝑡 𝑠𝑡𝑖𝑚𝑢𝑙𝑎𝑡𝑒
𝐶𝑜𝑟𝑡𝑒𝑥
𝑐𝑎𝑢𝑠𝑒𝑠
𝑛𝑜 𝑚𝑜𝑣𝑒𝑚𝑒𝑛𝑡

→ →
During movement: 𝐺𝑃𝐼 + 𝑆𝑁𝑝𝑟 𝑖𝑛ℎ𝑖𝑏𝑖𝑡𝑠 𝑇ℎ𝑎𝑙𝑎𝑚𝑢𝑠
𝑑𝑜𝑒𝑠 𝑛𝑜𝑡 𝑠𝑡𝑖𝑚𝑢𝑙𝑎𝑡𝑒

→ → → → →
𝐶𝑜𝑟𝑡𝑒𝑥 𝑆𝑁𝑃𝑐 𝐷𝑜𝑝𝑎𝑚𝑖𝑛𝑒 𝑆𝑡𝑟𝑖𝑎𝑡𝑢𝑚 𝐺𝑃𝐼 + 𝑆𝑁𝑝𝑟
𝑔𝑜𝑒𝑠 𝑡𝑜 𝑟𝑒𝑙𝑒𝑎𝑠𝑒𝑠 𝑠𝑡𝑖𝑚𝑢𝑙𝑎𝑡𝑒𝑠 𝑖𝑛ℎ𝑖𝑏𝑖𝑡𝑠 𝑓𝑟𝑒𝑒𝑠
→ →
𝑇ℎ𝑎𝑙𝑎𝑚𝑢𝑠 𝐶𝑜𝑟𝑡𝑒𝑥 𝑚𝑜𝑣𝑒𝑚𝑒𝑛𝑡
𝑠𝑡𝑖𝑚𝑢𝑙𝑎𝑡𝑒 𝑐𝑎𝑢𝑠𝑒𝑠

Indirect Pathway
At rest: GPe ≠ subthalamus ≠ GPI ≠ Thalamus ≠ Cortex -> no mvmt of antagonist
→ → → →
During Movement: GPe 𝑖𝑛ℎ𝑖𝑏𝑖𝑡𝑠 subthalamus
𝑖𝑛ℎ𝑖𝑏𝑖𝑡𝑠
GPI
𝑖𝑛ℎ𝑖𝑏𝑖𝑡𝑠
Thalamus
𝑖𝑛ℎ𝑖𝑏𝑖𝑡𝑠
Cortex

→ → → → →
𝐶𝑜𝑟𝑡𝑒𝑥 𝑆𝑁𝑃𝑐 𝐷𝑜𝑝𝑎𝑚𝑖𝑛𝑒 𝑆𝑡𝑟𝑖𝑎𝑡𝑢𝑚 𝐺𝑃𝐸
𝑔𝑜𝑒𝑠 𝑡𝑜 𝑟𝑒𝑙𝑒𝑎𝑠𝑒𝑠 𝑠𝑡𝑖𝑚𝑢𝑙𝑎𝑡𝑒𝑠 𝑖𝑛ℎ𝑖𝑏𝑖𝑡𝑠 𝑓𝑟𝑒𝑒𝑠
→ → → →
𝑆𝑢𝑏𝑡ℎ𝑎𝑙𝑎𝑚𝑢𝑠 𝐺𝑃𝐼 𝑇ℎ𝑎𝑙𝑎𝑚𝑢𝑠 𝐶𝑜𝑟𝑡𝑒𝑥 𝑚𝑜𝑣𝑒𝑚𝑒𝑛𝑡
𝑠𝑡𝑖𝑚𝑢𝑙𝑎𝑡𝑒 𝑐𝑎𝑢𝑠𝑒𝑠 𝑠𝑡𝑖𝑚𝑢𝑙𝑎𝑡𝑒 𝑐𝑎𝑢𝑠𝑒𝑠

Neurotransmitter
 In the Brain
o Inhibit: GABA
o Excitatory: Glutamate
 Basal Ganglia
o Inhibit: DA
o Stimulate: Ach
o Primary Efferent Nucleus: GPI, SNPr
o Primary Afferent Nucleus: Striatum, Subthalamus

Parkinsonism (Hypokinetic)
 A group of disorder with primary disturbances in the dopamine system of Basal Ganglia
o Primary PD – idiopathic – MC type of PD
o Secondary PD – with known etiology – LC type of PD
o Parkinson’s Plus – mimic PD

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Primary PD
 Idiopathic, Genetic
 Gene: PINK1, PARK1, LRRK2
 Paralysis Agitans, Shaking Palsy
 Slowly progressive disorder of CNS with motor and non-motor symptoms
 Progressive loss of dopaminergic cells that produces DA in the Substansia Nigra
 Maybe 2° to hyperactivity of cholinergic cells in the striatum
 MRI
o (+) Paleness
o (+) Lewy Bodies
 Nonmotor > Motor Symptoms
o 30-60% of the Substansia Nigra should be damaged before seeing motor sx (Sullivan)
 Dx Tool
o Apomorphine Test
 If the px reacts = (+) PD
o 2 out of 4 cardinal signs
 Epidemiology
o M>F
o 40-60 y/o
o Young Onset: 21-40 y/o
o Juvenile Onset: <21 y/o

Secondary PD (Etiology)
1. Post-infectious
a. Encephalitis Lethargica
2. Post Traumatic PD:
a. 2° repetitive Microtrauma to brain
b. Common in boxers
c. Dementia Pugilistica aka Punch-Drunk Syndrome
3. Toxic PD
a. MC – Manganese
b. Pesticides
c. Cyanide
d. Carbon Disulfide
e. Ethanol
f. 1 Methyl-4Phenyl-1236-Tetrahydropyridine (MPTP)
4. Metabolic PD
a. Wilson’s Disease aka Hepatolenticular Degeneration
i. Buildup of Copper in the Brain
ii. Excess copper goes to
1. Eye: Kayser Fleischer Ring
2. BG: Lentiform Nucleus
3. Liver: becomes Large & Firm
5. Drug Induced PD
a. 2° Neuroleptic Drugs, Anti-depressant Drugs, Anti-HTN Drugs

Cardinal Signs
 Tremor
 Rigidity
 Akinesia/Bradykinesia
 Postural Instability – Advanced Stage
 Tremor – Resting
o MC Symptom
o MC presenting Symptom

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Signs
 Hand – Mc pill-rolling tremor
o 3-5 Hz, 4-6 Hz, 4-7 Hz
 FA – Pron-Sup
 Jaw & Tongue
 Postural Tremor
 Legs
 Action Tremor

Rigidity
 Velocity independent resistance to passive movement
 Proximal to distal

Leadpipe Cogwheel
Sustained resistance to passive jerky-ratchet like resistance
Uniform throughout 2° superimposed tremor
aka Plastic Rigidity aka Intermittent Rigidity

Manifestations
 Akinesia – delayed initiation
 Bradykinesia – slowness of movement (most disabling)
 Hypokinesia – decrease in amplitude of movement
 Hypomimia – Masked face
 Bradyphrenia – slowness of thought
 Micrographia – small handwriting
 Postural Instability
o Last symptom to occur
o ↑ risk of fall
o Indicative of advanced stage PD
 (+) Simian Posture
o Stopped forward
o Forward head – shadow pillow posture
o Protracted Sh
o Sh ADDIR
o Elbow Flexion
o Hip Flexion
o Knee Flexion
 Striatal Hand
o FA Pro
o Wrist & MCP Flexion
o IP Extension
 Striatal Foot
o DF
o Inv
o Big Toe Ext

Gait Difficulty
 Shuffling Gait
o ↓ BOS
o ↓ Step & stride Length
o ↓ Velocity

Other Gait Patterns

 Festination – small steps with ↑ speed
o Advanced Stage
o Displaced COG

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 Freezing of Gait
o Off State Phenomenon
 Fear of Falling
o Cautious Gait

Others
 Pain – MC Source of Limb rigidity
 Postural Stress Syndrome
 Restless Leg Syndrome
 CN Affectation “1973”
o 3 – Gaze Palsy
o 7 – Facial Palsy
o 9 – (-) Gag Reflex
o 1 – Anosmia
 Dysphagia
 Sialorrhea – Drooling
 Speech Problem
o Hypokinetic Dysarthria
 Depression
 Sleep Disorder
o Insomnia
o Excessive Daytime Sleeping
o REM – sleep behavior Disorder
 Autonomic Dysfunction
o Erectile Dysfunction
o Constipation
o Urinary Incontinence (Nocturia)
o Excessive Sweating
o Seborrhea
o Orthostatic Hypotension

Prognosis
Positive
T remor
R igidity
F amily History

 Negative
o Bradykinesia
o Akinesia
o Gait Difficulty
o Cognitive Impairment
o Postural Instability
o Late Age Onset

Modified Hoehn Yahr Scale

 0 – No Disability
 1 – Unilateral D/A
 1.5 – Unilateral (+) Axial
 2 – Bilateral without balance problem
 2.5 – bilateral with recovery on pull test
 3 – Bilateral with balance problem, unsteadiness, impaired righting reflex, px can live independently
 4 – all s/sx are (+) and severe, standing and walking only possible with assistance, px is physical dependent
 5 – confined to bed or w/c

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Pharma
1. Dopamine Replacement
a. 1 hour before or after meal
b. Low Protein diet
c. Levodopa taken 1 hour after 1st dose
d. Levodopa + Carbidopa
i. Sinemet – Gold Standard
e. Tx for Bradykinesia & rigidity
f. Honeymoon Period: 7-8 years (time when DA is most effective)
g. Wearing Off State: meds not affective anymore
i. Adverse Effects
1. Visual Hallucination – MC
2. Peak Dose Dyskinesia
a. Face – Grimace
b. Limb - Choreoathetosis
3. Dystonia – end dose
a. MC – foot (clawing of toes)
4. End Dose Deterioration
5. On-Off Phenomenon
6. Akathisia – restlessness
7. Nocturia
8. Nausea
9. Dryness of Mouth
10. Mood/Personality/Sleep Disorder
11. Orthostatic Hypotension
2. Dopamine Agonist
a. ↑ the sensitivity of Dopamine Receptors
b. Examples
i. Bromocriptine
ii. Pramipexole
iii. Pergolide
iv. Ropinirole
v. Cabergolide
vi. Amantadine
vii. Apomorphine
3. Anticholinergic
a. Tx for tremor
b. eg. Trihexyphenidyl
4. MAO-Inhibitors
a. Mono Amine Oxidase
b. Eg. Rasagiline, Selegiline

Parkinson’s Plus Syndrome

1. Progressive Supranuclear Palsy
a. Gait Difficulty
b. Supranuclear Palsy
c. Difficulty in downward gaze – leads to Ophthalmoplegia
d. Onset – 5th decade of life
2. Corticobasal Ganglionic Degeneration
a. Asymmetric Akinetic Rigid Syndrome
b. Apraxia
c. Alien Hand Syndrome
3. Multisystem Atrophy
a. BG system – striatonigral degeneration
b. Autonomic System – Shy dragger syndrome
c. Cerebellar System – Olivopontocerebellar Atrophy

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4. PD with Early Dementia

a. Alzheimer’s Disease
b. Diffuse – Cortico Lewy Bodies
c. Guamanian ALS

Hyperkinetic Movement Disorders

A. Athetosis
a. Globus Pallidus
b. Heubner
c. C/L
d. Proximal > Distal
e. Slow & Fluid
f. Slow writhing
g. Worm-like/snake-like
h. Inability to stop distal limb
B. Ballismus
a. Subthalamus
b. PCA
c. C/L
d. Proximal > Distal
i. Uni – Hemiballismus
ii. Bilat – Biballimus
e. Large amplitude
f. Wild/Violent
g. Wild Flinging
C. Chorea
a. Neostriatum
b. Lenticulostriate
c. C/L
d. Distal > Proximal
e. Brief, rapid, jerky, forceful, purposeless movement of distal limb
D. Dystonia
a. Putamen
b. Lenticulostriate
c. C/L
d. Abnormal repetitive twisting and torsional contraction of group of muscles that leads to abnormal
posture
e. Examples
i. Cervical Dystonia – MC
ii. Blepharospasm – sustained eye closure
iii. Oromandibular Dystonia – oral & facial muscle
iv. Meige Syndrome – combination of cervical + oromandibular dystonia
v. Writer’s Cramp Dystonia – task specific dystonia, common in writers, painful & tight forearm
muscle

Neostriatum
C horea
P utamen
D ystonia
G lobus Pallidus
A thetosis
S ubthalamus
H emiballismus
E. Tics
a. Repetitive Stereotypic Intermittent movement seen in head neck & trunk
b. Px is aware

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F. Gilles Dela Tourette’s Syndrome

a. MC cause of inherited tics
b. M > F
c. < 21 y/o
d. OCD
e. Complex Tics
i. Vocal + Motor Tics
ii. Vocal – Profanity – Coprolalia
iii. Motor Tics – Ballistic – Copropraxia
f. > 1 year
G. Tardive Dyskinesia
a. 2° Long term use of drugs
i. eg. Peak dose dyskinesia
H. Stereotypy Methamphetamine
a. Head Nodding
b. Head Banging
c. Body Rocking
d. Purposeless, uniform, repetitive, voluntary movement of whole body area
I. Myoclonus
a. Brief, Sudden irregular, asynchronous, contraction of group of muscle
J. Myotonia
a. Delayed relaxation of muscle after contraction
K. Myokinia
a. Contraction of muscle fiber under skin with rippling like appearance

Multiple Sclerosis
General Information
 Demyelinating Disease of CNS
 Autoimmune Disease
o Segmental Demyelination
o Inflammation
o Gliosis
 Charcot’s Triad – cardinal sign of MS

I ntention Tremor
N ystagmus
S canning Speech

 Etiology: Idiopathic
 Risk Factors
o F>M
o 20-40 y/o
o Geographical – Temperate
o Hereditary
o Smoking
o ↓ Vitamin D Level
o ↑ intake of dairy products

Medications
 Immunomodulatory – Interferon B
B etaseron
E xtavia
A vonex
R ebif

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 Acute MS – Corticosteroids
 Hallmark: plaques formation
P eriventricular White Matter
O ptic Nerve
B rainstem
C ortex
C erebellum
C ST
C ervical Spinal Cord (Posterior White Column) | (+) Lhermittes

4 Distinct Patterns
 Type 1: cell mediated destruction of myelin sheath by T Cells
 Type 2 (MC): cell mediated destruction of myelin sheath by T Cells & immunoglobulins
 Type 3: Apoptosis of Oligodendrocytes
 Type 4 (LC): Primary Degeneration of Oligodendrocytes

Clinical Types (Box 16.1 O’Sullivan)

 Type I: Relapsing Remitting/Exacerbating-Remitting MS
o 85%/65%
o MC
o MS will last hours to days
o Periods between can last from months to years to decades
o Relapsing Remitting with complete remission
o Relapsing Remitting with incomplete remission (MC)
o Onset: sensory – paresthesia, optic neuritis
 Type II: Secondary Progressive MS
o 1st Relapsing Remitting becomes Progressive
o Only 20% of relapsing remitting becomes progressive (2nd MC)
 Type III: Primary Progressive
o 10%
o M>F
o Older Onset
o Motor Onset:
o In MRI: fewer lesions
 Type IV: Progressive-Relapsing MS
o 5%
o Least Common
o Progressive Disease in the beginning but begins to have attacks later in the course

Benign vs Malignant MS
Benign Malignant/Marburg Disease
15 years of Stability rapid onset almost continual progressive disease that leads to significant disability or death
within short period of time
Kurtzke Expanded
Disability Scale = <3

7 Functional System
V isual System
P yramidal System
S ensory System
C erebellum
B rainstem
B owel/Bladder/Sexual
Mental

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 Visual System
o Optic Neuritis: inflammation of optic nerve with icepick like sensation behind eye and blurring or graying
of vision that leads to eye blindness.
o Visual Scotoma: presence of dark spots in the visual field
o Nystagmus
o Ophthalmoplegia
 Pyramidal System
o UMNL
o Fatigue – most common, most disabling, most troubling, more pronounced in the afternoon
o Uthoff’s Phenomenon: anything that may increase body temperature will lead to pseudo-exacerbation
of symptom
 Criteria
 Reversible
 <24 hrs
 Sensory System
o Paresthesia: MC presenting symptom
o Pain: electric shock-like, burning
o Face Paroxysmal Pain Syndrome
 Trigeminal Neuralgia
 Tic Doloreux
o Limb
 Paroxysmal limb pain
 MC
 LE > UE
 Dysesthesia Limb
o Trunk
 Painful band sensation around trunk
 “MS Hug”
o Headache
 MC Pain complaint
o Hyperpathia
 Hypersensitivity to light stimulus
 Cerebellum
o Ataxias: uncoordinated movement
 Dysmetria
 Dyssynergia
 Dysdiadochokinesia
o Gait Ataxia – “Drunkenness”
o Intention Tremor
 Brainstem
o CN 2, 5, 7, 8
o Speech Problem – “Controlling the Volume”
 Bowel/Bladder/Sexual
o MC Bowel – Constipation
o MC Bladder – Detrusor Hyperreflexia
o Sexual

Female Male
Loss of Libido Loss of Libido
↓ Sensation ↓ sensation
Dryness of Vagina Difficulty ejaculation
Difficulty Reaching Orgasm Impotence

 Mental
o Dementia

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o Attention Deficit
o Memory Loss

Prognosis
Positive Negative
Female Male
<40, <35 <40, <35
Sensory Onset Motor Onset
One Symptom @ Onset Polysymptomatic
Relapsing Remitting Progressive

McDonald’s Criteria
Attacks Lesion
Attacks 2 2
1 2
Probable
2 1
Possible 1 1

Kurtzke Expanded Disability Scale

0 Normal
1 1 functional system
No disability, minimal signs in
1.5 2 functional system
2 1 functional system
Minimal Disability in
2.5 2 functional system
3 1 functional system
Moderate Disability in
3.5 2 functional system
4 500m
4.5 Fully Ambulatory without rest without 300m
5 assist 200m
5.5 100m
6 Intermittent Unilateral Assistance 100m
6.5 Constant Bilateral Assistance 20m
7 unable to walk beyond 5 meters
7.5 cannot take few more steps
8 can be out of bed much of the day
Bedbound
8.5 in bed much of the day
9 can eat, talk, swallow
Bedridden
9.5 cannot eat, talk, swallow
10 Death

TBI
 Alteration of brain function 2° external force

Causes of TBI
 Falls > MVA > Assaults > Others
o MVA – SCI
o The most common cause of Severe TBI – MVA

Types of TBI
 Open Head – penetrating
 Close Head – non-penetrating, MC

Pathophysiology
Primary Brain Injury
 Diffuse Axonal Injury - 2° high velocity forces (acceleration-Deceleration-Angular Force)

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o Distinguishing feature of TBI

o Responsible for initial LOC & Coma
o Common Sites: Corpus Callosum, Parasagittal white matter, Pons, Midbrain
 Concussion
o Mild TBI
o Mild DAI
o 2° shaking of brain
o Alteration of Consciousness
 Coma
 If (-) Sleep/wake cycle
 (-) arousal system
 Requires (+) Ventilatory support
 Can take from days to decades to wake up
 GCS Score 3-8
 Vegetative State
 (+) sleep/wake cycle
 (-) Awareness
 (-) Ventilatory Support
 (+) reflex smile/cry
 Persistent Vegetative State: > 30 days/1 year (poor prognosis)
 Minimally Conscious State
 (+) minimal evidence of self & environmental awareness
 Obtunded State
 Often Sleeps
 ↓ interest
 Delayed Reaction time
 Stupor
 Unresponsive state, but can be aroused briefly via vigorous repetitive sensory stimulus
 Contusions
o Cortical bruises
o 2° low velocity forces
 Coup – at the site of impact
 Countercoup Injury – opposite site of impact
o Sites
 Frontal (Inferior) – Behavioral
 Temporal (Anterior) – Memory
o Behavioral Changes
 Agitated – Excited
 Aggressive – Violent
 Apathy - ↓ Interest
 Irritable – Moody
 Impulsive – Quick
o Post Traumatic Amnesia
 Length of time from the injury until the time in which px remembers ongoing events
 Measured by
o Galveston Orientation & Amnesia Test (GOAT)
 100 Questions
o Orientation Log Test

Secondary Brain Injury

1. ↑ ICP
a. Normal
i. 5-10 mmHg
ii. 4-15 mmHg
iii. <20 mmHg

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b. >20 mmHg
i. (+) Nausea
ii. (+) Vomiting
iii. (+) Papilledema
iv. CN 2 Affectation
c. Medications
i. Diuretics
ii. Mannitol
d. Interventions
i. Elevate the head up to 30° from supine
2. Normal Pressure Hydrocephalus
a. Adult – Communication
b. ICP Flow “CLMTSFLMSA”

Ventriculomegaly
↓
Normal P°
↓
Triad

I ncontinence (Urinary)
G ait Ataxia
D ementia

3. Herniation
Uncal Central Tonsilar
C erebral Peduncle Paresis Midbrain-Pons: decerebrate Medulla Oblongata: alteration of
R AS Coma rigidity PR, RR, HR
O culomotor N. Gaze Palsy RAS – Coma Cerebellar Tonsils: neck pain
P CA Hemianopsia RAS – Coma
CN – 3, 7, 12
MC Involved Nerve in TBI – CN3

Scales
A. Modified Ashworth Scale
0 No ↑ in muscle tone
1 Catch followed release
1+ Catch followed min resistance / resistance is less than half of remaining ROM
2 More marked ↑ in muscle tone but the joint is easily moved
3 considerable ↑ muscle tone and passive movement is difficult
4 Affected parts is rigid flexion or extension

B. Tardieu Scale
0 no resistance through the passive movement
1 slight resistance without clear catch
2 slight resistance with clear catch
3 fatigable Clonus - <10sec
4 Non-fatigue Clonus – > 10sec

C. Classification of Severity of TBI

Mild Moderate Severe
L OC 0-30 minutes 30 min to 1 day > 1 day
P TA 0-1 day 1-7 day > 7 day
G CS 13-15 9-12 3-8

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D. Glasgow Coma Scale (Gold Standard)

A. It has the highest reliability

Eyes
4 Spontaneous
3 to speech (command, request, directed to)
2 to pain (sternal rub, triceps/anterior FA pinch)
1 Closed
Motor
6 Follows Command
5 localized pain (pull therapist hand)
4 Withdraws to pain
3 Flexes to pain
2 Extends to pain
1 No response
Verbal
5 Oriented
4 Disoriented/confused
3 Inappropriate
2 Incomprehensible (moaning)
1 Silent

E. Glasgow Liège Scale

1 (+) Oculocardiac reflex Pressure in eye = bradycardia
2 (+) horizontal Oculocephalic Doll’s Eye Phenomenon
3 (+) Pupillary light reflex Accommodation Board Exam
4 (+) Vertical Oculocephalic Doll’s Eye Phenomenon
5 (+) Fronto Orbicular Reflex Glabellar Tap

F. Glasgow Outcome Scale – Extended

8 Upper completely
Good Recovery
7 Lower Return to previous lifestyle with some problems
6 Upper with modification
Moderate Disability
5 Lower Independence in ADLS but will not return to previous lifestyle
4 Upper Assistance 8hrs/day
Severe Disability
3 Lower Assistance 24hrs/day
2 Vegetative State
1 Dead

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G. Ranchos-Los Amigos
I No response
II Generalized Response
III Localized Response
IV Confused-Agitated
Confused-Inappropriate
V
Confused Non-Agitated
VI Confused-Appropriate
VII Automatic-Appropriate
VIII Purposeful-Appropriate
IX Purposeful-Appropriate
X Purposeful-Appropriate
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Px is in deep sleep
Responses maybe physiologic body changes
Responses are limited & same
responses are not related to stimulus
stereotypic response
Responses are now related to stimulus
May follow simple commands inconsistently
Px has bizarre behavior
Px is in heightened state of activity
Px has no short/long term memory
Px may follow simple commands fairly consistent
No learning is possible
Px has goal directed behavior
Px may follow simple directions consistently
(+) Carryover of relearned tasks
Px has robot-like behavior
Judgement impaired
new learning at ↓ Rate
Environmental Awareness
Abstract reasoning
New learning without supervision
with standby Assistance upon request
Modified Independence