ROLE OF DUTY DOCTORS IN NEUROLOGICAL DISORDERS

DR GANESHGOUDA MAJIGOUDRA
CONSULTANT NEUROLOGIST
NANJAPPA HOSPITALS DAVANAGERE
ganeshgoudam4@gmail.com
9380906082
 INTRODUCTION

• Name
• Age
• Sex
• Handedness
• Resident of
• Education
• Occupation
• Informant
• Reliability
 STROKE PATIENT

• 1) HISTORY-
• Onset of symptoms- Time...............Date............
• Activity at stroke onset –
• Wake up stroke-
• Time of presentation to Emergency -
• Symptoms- onset & course
• (a) Headache –(b) Vomiting (c) Loss of conscious(d) Seizures (e) Weakness (f) Side(g)
Aphasia(h) Facial paresis (i) Visual disturbances(j) Dysphagia
• (k) Dysarthia (l) Ataxia (m)Vertigo / tinnitus
 STROKE PATIENT

2) RISK FACTOR ASSESMENT-

• 1) Hypertension –
• 2) Diabetes –
• 3) Dyslipidemia-
• 4) Smoking-
• 5) Alcohol intake-
• 6) Atrial fibbrillation-
• 7) RHD or CAD
• 9) Obesity
• 10) H/O TIA or stroke-
 HEADACHE
SNOOP4 (“snoop for” red flags)

• Onset,
• Duration
• Severity – VAS Score
• Site ,frequency,
• Aggreviating factor
• Releiving factors
• Associated symptoms
• Photophobia,phonophobia, nausea, vomiting
• Double vision, slurred speech, swallowing difficulty, walking
imbalance
 NECK AND BACK ACHE

• Onset, duration, site, severity

• Injury ,weight lift
• Past surgery
• Radiating or localized
• Aggravating or relieving factors
• Coughing sneezing straining will worsen ?
• Numbness/weakness of limbs, urinary disturbances
• Fever, weight loss, HIV, steroid intake, older age ,
 SEIZURES

• Age of onset, duration

• birth insult, growth developmental delay
• Any premonitory symptoms
• Urinary, stool incontinence , tongue bite, Rolling up of eyes/stare/grunting noise /abnormal
breathing pattern
• Tonic, clonic or nay jerky movements
• Limb onset
• Loss of consciousness and duration
• Family history, current drug dose and compliance
• Previous investigations
• Past history of trama, enchephelitis, stroke
 LOSS OF CONSCIOUSNESS

• Onset, Activity at the time of incident

• Preceded by
• Chest pain/Palpitation sweating/nausea/ vomiting/
• headache/giddiness/pre syncope/visual disturbance.
• Lasted for (Duration), Recovered after – Spontaneous/treatment
• Any injury sustained.
• Fever, headache, vomiting , limb weakness, speech disturbances, vertigo
• Syncope history/seizure history /stroke history/CAD/CKD/liver failure
• Alcohol/drug consumption/toxins
• Chronic malnutrition/systemic complaints/psychiatric disorders
 SPEECH DISTURBANCE

• Onset
• Comprehension
• Any spontaneous speech/word outflow
• Slurring
• Reading/writing/repetition
• Progression
• Any stress during speaking
• Tightness/looseness in tongue
• New words/ un understandable words
DIZZINESS/VERTIGO/GIDDINESS
 HISTORY AND EXAMINATION
Quality of dizziness
Vertigo or clear spinning Vestibular mechanism
Near faintness Cardiovascular/ hemodynamic mechanism
Other descriptions Mechanism less clear
Timing and duration

Brief recurrent spells (1 min) BPPV

Recurrent spells of dizziness (1 to 15 minute)
Recurrent dizziness (hours)
Chronic ongoing dizziness
(continuously for weeks)
Others - vascular, cardiac, psychological
Vertebrobasilar TIA, vestibular migraine, panic
attacks
Vestibular migraine or Meniere disease
(fluctuating hearing)
Anxiety or Vestibular migraine
Other causes - recovering vestibular
neuritis or brainstem/cerebellar lesions or
drug toxicity
 HISTORY AND EXAMINATION

Triggering circumstances
Specific head movement BPPV

Worsened by head movement Vestibular mechanism - central or peripheral

Exclusively on standing or walking ( not in Hemodynamic mechanisms

recumbent) Others - simple gait
unsteadiness
Tullio phenomenon/sound Superior canal dehiscence syndrome

Optokinetic motion sickness Vestibular mechanism

 HISTORY AND EXAMINATION
Associated symptoms

Unilateral hearing loss with spinning vertigo Labyrinthine disorders

Diplopia, dysarthria, or focal weakness or CNS vestibular mechanism

numbness with vertigo

Nausea Characteristic of vestibular (central / peripheral)

Nystagmus
Spontaneous direction-fixed Peripheral vestibular mechanism

Spontaneous vertical or horizontal gaze CNS

evoked nystagmus
 NEGATIVE HISTORY

• Injury/RTA/Trauma to the neck

• Abnormal behavior/nausea/vomiting
• Fever/chest pain/palpitations/cough/dyspnea/hemoptysis
• Bowel symptoms/Jaundice
• Oliguria/dysuria/hematuria/high colored urine
• Joint pain/rash/photosensitivity/oral ulcers/hair fall/seizures
• Dog bite/animal bite/vaccination/injection
• Alternative drugs/well water drinking/insecticides /exposure
• Carrying weight in head for long/neck pain for long
• skin lesions/Nodules
• Hypo/hyper thyroidism symptoms
• Blood transfusion
 PAST HISTORY

• 1. DM/TB/HTN/CAD/BA
• 2. Similar illness in the past
• 3. Animal bite/vaccination/injection in the past
• 4. Blood transfusion/jaundice
• 5. Major surgery
• 6.Drugs history/duration/dose
 PERSONAL HISTORY

• 1. Veg/Non veg/Well water drinking/food habits

• 2. Smoking/Tobacco/Alcohol/Substance abuse
• 3. Marriage/Children
• 4. High Risk behavior
 MENSTRUAL HISTORY

• 1. Menarche/Cycles/Menopause
• 2. LMP/Post menopausal bleed
• 3. Any surgery
 OCCUPATIONAL HISTORY

• 1. Nature/duration/intensity of exposure
• 2. H/O exposure to dye/paint/glass wares/med eqpts/jewellery
• 3. Plumbing/farming/insecticides
• 4. Vibrating eqpts/repeated trauma
 OTHER

• FAMILY HISTORY
• 1. Pedigree charting of possible genetic disease
• 2. H/O similar illness in the family

TREATMENT HISTORY
 GENERAL EXAMINATION

• 1. Consciousness/orientation/cooperative
• 2. Ht/Wt/BMI
• 3. Pulse-Rate/rhythm/volume/ All peripheral pulse /Delay/pulse
deficit/vessel wall/carotid bruit/shudder
• 4. BP mm Hg/Rt Arm supine/No significant postural fall
• 5. RR – rate/rhythm/type
• 6. P/I/C/C/L/E/JVP
GLASGOW COMA SCALE
 SYSTEMIC EXAMINATION

• 1. CVS
• a. Apical Impulse/chest wall symmetry/anomalies
• b. S1/S2/S3/S4/murmur/pericardial rub/knock

2. RS
• a. Chest wall symmetry
• b. Air entry/Breath sounds/adventitious sounds/pleural rub

3. P/A
• a. Distended/all quadrants moves equally with the respiration
• b. Soft/Non tender/organomegaly/free fluid/bowel sounds
• c. Hernial sites/peripheral signs of liver failure
 C N S E X A M I N AT I O N

• 1. HMF
• a. consciousness
• b. oriented to T/P/P
c. Language-Speech /Comprehension/Spontaneous speed/slurred speech
 C R A N I A L N E RV E S

• Vision/ pupils reaction to light

• Position of the eye at primary gaze
• Extra ocular movements
• Facial sensations touch/pain/temp/vibration/facial deviation on pain
• Uvular position
• Gag reflex
 MOTOR SYSTEM EXAMINATION

• a. Position/attitude of limbs

• b. Bulk (wasting/hypertrophy)

• c. Tone

• d. Power
 MOTOR SYSTEM EXAMINATION

REFLEXES
• Biceps
• Triceps
• Supinator
• Knee
• Ankle
• Plantar
 S E N S O RY S Y S T E M E X A M I N AT I O N

• a. Superficial sensations
I. First test pin prick sensation
II. Touch
III. Pain

Rhombergs sign
 CEREBELLAR EXAMINATION

• a. Nystagmus
• b. tremor
• c Finger nose test/Finger nose finger/Knee shin dragging test
• d. Pronation – supination (Disdiadochokinesia)

• Gait
 OTHER

• a. Postural hypotension
• b. Spine examination
 TO BE SEEN –TAKE NURSING STAFF HELP

• VITALS
• SUGARS
• GCS
• FOLLOW INSTRUCTIONS WRITTEN IN NOTES
• ANY ISSUES CALL
• CHECKLIST OF DRUGS
 TO BE SEEN

• TEAM WORK FOR CPR OR OTHER LIFE SAVING PROCEDURES

• BED POSITIONING
• SECURE LINE
• CALL LAB AND RADIO TECHICICIAN URGENTLY
• KEEP READY FOR RT FOLEYS INTUBATION IF NEEDED
 TO BE SEEN

• INFORM ABOUT NUSRING CARE; AIR BED,FEEDING,TRACHEOSTOMY

CARE,BED SORES, POSITIONING, EYE AND ORAL CAVITY HYGEINE
• IP/OUTPUT MEASUREMENT
• TEACHING ATTENDERS
• INFORM REPORTS TO CONSULTANTS
 TO BE SEEN

• DAILY NOTES
• ALWAYS ASK CONSULTANT INCHAREGE TO SEND INVESTIGATIONS IF
OTHER CONSULTANT MENTIONED IN REFERENCE
• MOBILIZE PATIENT ATLEAST 3 TIMES A DAY
 TO BE SEEN

• GIVE PREFERENCE TO SENIOR CONSULTANTS WHILE ATTENDING ROUNDS

• TRIAGE
• INFORM CONSULTANTS IMMEDIATELY IF ANY OPD /EMERGENCY PATIENTS
COME
• FOLLOW INSTRUCTIONS ADVISED IN WTSAPP GROUP
• POSTURAL BP MEASUREMENT
• NEURO CHECK LIST
• SECURITY ALERT
EMERGENCY PROFORMA
Name of duty doctor:
Date: Time:
Provisional diagnosis:
Differential diagnosis:
GCS:
Pulse:
BP:
RR:
Pupils:
O2 Saturation:
EOM and pupils:
Facial sensation:
facial motor:

Gag:
Motor power and DTRs
Planters:
Sensory:
Cerebellar:
Gait:
Spine:

Sugar:
Sodium:
Potassium:
KFTs,LFTs,ECG:,CT/MRI Brain,ABG:
Plan of action
Patient handed over to (after completion of duty):

Name and signature of the DD

ganeshgoudam4@gmail.com
Date and time 9380906082
Final outcome: