Neuroanatomy through Clinical Cases Chapter 1 – Flashcards

-A succinct statement that includes: 1) Age 2) Gender 3) Presenting Problem 4) 1 or 2 Historical places example: The patient is a 53 year old man with history of hypertension presents with crushing substernal pain of 1 hour duration

-complete history of current medical problems that brought the patient to medical attention -Should include: -Possible risk factors/ causes of current illness -Detailed chronological description of symptoms & Prior care

Prior medical & surgical history that is not directly related to the HPI example: Patient has a history of mildly enlarged prostate gland

-a brief head to toe of all medical systems -Goal is to pick up problems/ complaints missed in earlier parts of the history example: the patient has a mild upper respiratory symptoms for the past 4 days, with nasal congestion, but no cough, fever, or sore throat

-Medical history of immediate relatives that directly relates to the HPI -Example: The patients mother had diabetes and died at 76 of myocardial infraction, father died at 55, had diabetes and died from a stroke at 73

-The patients occupation, family situation, family situation, travel history and important habits ex: Environmental engineer, married with two children. No recent travel outside of the country. Denies ever smoking cigarettes or using drugs.

-a list of the patients current medications and any known general, food or drug allergies example: atenolol 50 mg PO daily. Sublingual Nitrogylcerin as needed. No allergies, no known drug allergies

1) General appearance 2) Vital Signs (T,P,BP,R) 3) HEENT 4) Neck 5) Back & Spine 6) Lymph Nodes 7) Chest/breasts 8) Lungs 9) Heart 10) Abdomen 11) Extremeties 12) Pulses 13) Neurologic 14) Rectal 15) Pelvic & Genitalia 16) Dermatologic

-All diagnostic tests, including: blood work, urine tests, electrocardiogram, and radiologic tests

summary/ formulation of patients main clinical features and most likely diagnosis (primary) -Differential diagnosis: list of alternative diagnoses

list of problems with proposed interventions & diagnostic procedures

-This is a 53 yr. old man with hypertension, family history of coronary disease who presents with substernal chest pain and ECG changes suggestive of anterolateral wall MI. -Continue IV nitroglycerin & IV heparin, check ECG & cardiac enzymes. Further workup to include echocardiogram, exercise stress test if enzymes are negative. If patient develops more pain, emergency cardiac catheterization should be done

-(1)Trauma/ mechanical: subnormal hematoma; herniated vertebral disc -(2)Vascular: infarct, hemorrhage, migraine, vascular malformations -(3)Tox/Met: Toxis such as a opiate OD -(4)Epileptic: partial or generalized seizures -(5) Inf/Inf/ Neo: Infectious such as bacterial meningitis: Inflammatory such as MS, neoplastic -(5) CSF circulation: hydrocephalus, pseudotumor cerebri, intracranial hypotension -(6) Deg/Dev: degenerative such as Alzheimer's; developmental such as TB -(7) Referred: left arm paresthesia due to cardiac ischemia -(8) Psych: Major depression, general anxiety disorder, conversion disorder -(9) Other/ non- near: loss of consciousness due to cardiac arrhythmia, impaired gait due to joint deformity

Traumatic disorders such as subdural hematoma; nontraumatic mechanical disorders such as herniated intervertebral disc

Infarct, hemmorrhage, migraine, vascular malformations

Partial or generalized seizrues

Hydrocephalus, pseudotumorcerebri, intracranial hypotension

Toxic disorders such as opiate overdose; metabolic disorders such as hepatic encephalopathy (DEENO - mnemonic for Drugs, Electrolytes, Endocrine, Nutrition, Organ Failure)

Infectious disease (eg. bacterial meningitis); inflammatory disease (eg. multiple sclerosis); neoplastic diseases (eg. glioblastoma multiforme)

degenerative disorders (eg. alzheimer's disease); developmental disorders (eg. tuberous sclerosis)

left arm parasthesias due to cardiac ischemia

Major depression, conversion disorder

Loss of consciousness due to cardia arrhythmia, impaired gait due to joint deformity

General History and Physical Exam