Neurology – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Wed, 12 Jul 2023 09:29:44 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.11 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png Neurology – ClinCaseQuest https://clincasequest.hospital 32 32 National Institutes of Health Stroke Scale (NIHSS) – Online calculator https://clincasequest.hospital/nihss/ Thu, 22 Jun 2023 16:34:55 +0000 https://clincasequest.hospital/?p=35594 The National Institutes of Health Stroke Scale (NIHSS) is a scale designed to assess the neurological status of a stroke patient. The scale assesses level of…

Сообщение National Institutes of Health Stroke Scale (NIHSS) – Online calculator появились сначала на ClinCaseQuest.

]]> The National Institutes of Health Stroke Scale (NIHSS) is a scale designed to assess the neurological status of a stroke patient. The scale assesses level of consciousness, eye movements, visual fields, facial muscle function, limb strength, sensory function, coordination (ataxia), language (aphasia), speech (dysarthria), and unilateral spatial neglect (neglect).

Before the assessment, pay attention!

  • Rate all sections of the stroke scale in the order presented and record the score in each section immediately.
  • Do not return to previous sections or change grades.
  • Follow the instructions for each review. Scores should reflect what the patient actually did, not what you think they can do.
  • Record grades during review and work quickly.
  • Except for the specified cases, do not teach the patient (in particular, do not insist that he exert as much effort as possible).


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If physical obstacles such as tracheal intubation, language barrier, facial or tracheal injury/bandaging prevent a full evaluation, use discretion. Grade “3” should be chosen only in the case when the patient does not react with movements (except for reflex ones) to painful stimuli

Ask the patient how old he is and how old he is. The answer must be exact – do not give part of the points for an approximate answer. Patients with aphasia or significant impairment of consciousness who do not understand the question receive a score of “2”. Patients who are unable to speak due to tracheal intubation, facial or tracheal injury/bandage, severe dysarthria (for any reason), language barrier, or other problem not caused by aphasia receive a “1”. It is important to evaluate only the first response and not to help the patient with any words or actions

Ask the patient to open and close the eyes and make a fist and spread the fingers of the less affected hand. If the fingers cannot be used, give another command that involves one action. When the attempt was clear, but it was not completed due to muscle weakness, a point is awarded for it. If the patient does not understand the verbal command, show the task (using sign language) and evaluate the response (did not perform any, performed both or one of the commands). For a patient with physical injuries, amputation of an arm, or other disabilities, give another simple one-step order. Rate only the first attempt

Assess only horizontal eye movements. Score for voluntary or reflex (oculocephalic reflex) eye movements, without caloric tests. If the patient’s eyeballs are turned sideways in pairs, but during voluntary or reflex movements their position changes, the score is “1”. If the patient has a peripheral lesion of the cranial nerve that provides movements of the eyeball (III, IV or VI), the score is “1”. Assess eye movements in all patients with aphasia. In a patient with eye injuries, bandages, blindness and other violations of acuity or visual fields, reflex movements should be checked – the choice is left to the clinician. Sometimes movements in one direction and in the other direction away from the patient while maintaining contact between the eyes make it possible to detect partial paralysis of the gaze

Assess the upper and lower quadrants of the visual fields using a confrontational test (counting fingers or, if not possible, threatening eye movements). You can encourage the patient, but if the patient accordingly looks in the direction of the moving finger, evaluate it as normal. If one eye is blind or removed, assess the visual fields of the other eye. The grade “1” is given only in case of clear asymmetry of the visual fields, including quadrantanopsia. If the patient is blind (for any reason), score “3”. Immediately perform simultaneous double stimulation. If there is a selective lack of attention, give the patient 1 point and take this into account in section 11

Ask (or encourage with gestures) that the patient shows his teeth, raises his eyebrows and closes his eyes tightly. In patients with impaired consciousness or those who do not understand speech, assess the symmetry of grimaces and response to painful stimuli. If the face is not visible (due to injury/bandaging, tracheal intubation, or other reasons), remove all obstructions as much as possible

Assess each limb in turn, starting with the least affected. Give the patient’s hand the initial position: straighten the patient’s hand (palm down) at an angle of 90 degrees (if the patient is sitting) or 45 degrees (if the patient is lying) to the body – and ask him to hold it like that. Lowering means the downward movement of the hand in the first 10 seconds. Encourage the patient with aphasia with a commanding voice and gestures, but do not cause pain. For cases of amputation or ankylosis of the shoulder joint only, indicate that this section cannot be assessed (U/A – cannot be assessed) and provide a clear written explanation

For example, amputation, joint ankylosis, other

For example, amputation, joint ankylosis, other

Assess each limb in turn, starting with the least affected (always in a horizontal, face-up position on the back). Give the patient’s leg the starting position: at an angle of 30 degrees to the bed – and ask him to hold it like that. Lowering means the downward movement of the leg in the first 5 seconds. Encourage the patient with aphasia with a commanding voice and gestures, but do not cause pain. For cases of hip amputation or ankylosis only, indicate that this section cannot be assessed (U/A) and provide a clear written explanation

For example, amputation, joint ankylosis, other

For example, amputation, joint ankylosis, other

In this section, signs of unilateral damage to the cerebellum are revealed. Ask the patient to keep his eyes open during the examination. In case of visual disturbances, perform the test in the preserved field of vision. Perform “toe-nose-toe” and “heel-knee” tests on both sides; score for ataxia only when the ataxia is greater than the weakness. If the patient does not understand speech or is paralyzed, there is no ataxia (score 0). In cases of amputation or joint ankylosis only, indicate that this section cannot be assessed (U/A) and write a clear explanation

For example, amputation, joint ankylosis, other

Assess the patient’s sensitivity or grimaces during injections with a disposable pin or avoidance of painful stimuli (in case of significant impairment of consciousness or aphasia). Consider only the loss of sensitivity from a stroke. Check carefully in different parts of the body (arms, but not hands, legs, torso, face) to reliably rule out hemihypesthesia. Score “2” only when there is no doubt that the patient has a very significant or complete loss of sensitivity. Therefore, rate a patient with impaired consciousness or aphasia as “1” or “0”. Give 2 points to a patient with a truncal stroke and bilateral loss of sensation. If the patient is unresponsive and has tetraplegia, determine the score “2”. Immediately give 2 points to a patient in a coma (score “3” in subsection 1A) in this section

Assess the patient’s sensitivity or grimaces during injections with a disposable pin or avoidance of painful stimuli (in case of significant impairment of consciousness or aphasia). Consider only the loss of sensitivity from a stroke. Check carefully in different parts of the body (arms, but not hands, legs, torso, face) to reliably rule out hemihypesthesia. Score “2” only when there is no doubt that the patient has a very significant or complete loss of sensitivity. Therefore, rate a patient with impaired consciousness or aphasia as “1” or “0”. Give 2 points to a patient with a truncal stroke and bilateral loss of sensation. If the patient is unresponsive and has tetraplegia, determine the score “2”. Immediately give 2 points to a patient in a coma (score “3” in subsection 1A) in this section

Ask the patient to describe what is depicted in the proposed picture, name the depicted things and read the sentence. Assess language comprehension based on responses and following commands during a general neurological examination. If visual disturbances interfere with the examination, ask the patient to name things that are placed in his hand, repeat phrases and speak. In the case of tracheal intubation, ask the patient to write. A patient in a coma (score “3” in subsection 1A) immediately receives 3 points in this section. If patient 42 is unconscious or uncooperative, rate the patient at your own discretion, but assign 3 points only when the patient is mute and unresponsive

Ask the patient to describe what is depicted in the proposed picture, name the depicted things and read the sentence. Assess language comprehension based on responses and following commands during a general neurological examination. If visual disturbances interfere with the examination, ask the patient to name things that are placed in his hand, repeat phrases and speak. In the case of tracheal intubation, ask the patient to write. A patient in a coma (score “3” in subsection 1A) immediately receives 3 points in this section. If patient 42 is unconscious or uncooperative, rate the patient at your own discretion, but assign 3 points only when the patient is mute and unresponsive

When there are no significant disturbances, assess the patient’s pronunciation by asking him to read and repeat the words on the page. If the patient has severe aphasia, assess the clarity of pronunciation and spontaneous speech. Only in the case of intubation or other physical barriers to speech, indicate that this section is not assessable (U/A) and provide a clear written explanation. Do not explain to the patient exactly what you are evaluating

For example, intubation, physical obstruction, other

During the preliminary examination, you may have received quite a bit of information about lack of attention or selective perception. If simultaneous double stimulation is not possible due to significant narrowing of the visual fields (hemianopsia), and skin sensitivity is preserved, choose a score of “0”. If a patient with aphasia pays attention to stimuli from both sides, the score is “0”. If there is a lack of visual attention to part of the space or anosognosia, this confirms the disorder. Since these violations are only assessed when they are present, this section is never unassessable

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]]> Clinical Presentation Alzheimer Disease https://clincasequest.hospital/alzheimer-disease/ Tue, 30 Aug 2022 09:32:43 +0000 https://clincasequest.hospital/?p=34235 Learning Objectives: 1. Discuss the differential diagnoses of dementia 2. Identify the clinical manifestations of Alzheimer disease 3. Discuss the diagnosis of Alzheimer disease 4.…

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Clinical case Alzheimer disease


    Learning Objectives:

  • 1. Discuss the differential diagnoses of dementia
  • 2. Identify the clinical manifestations of Alzheimer disease
  • 3. Discuss the diagnosis of Alzheimer disease
  • 4. Describe the pathologic features of Alzheimer disease
  • 5. Review the mechanism of action of drugs used in the management of Alzheimer disease


    • Dementia – the loss of cognitive ability severe enough to represent a decline from a previous level of functioning.

    Alzheimer disease, Alzheimer, manifestations of Alzheimer's disease, diagnosis of Alzheimer's disease, what is Alzheimer disease, features of Alzheimer's disease, pathology of Alzheimer disease, Alzheimer disease in Down syndrome, treatment of Alzheimer disease, Clinical presentation of Alzheimer disease, dementia, dementia diagnosis, Vascular dementia, Frontotemporal dementia, Pick disease, Creutzfeldt-Jakob disease, Huntington disease

    1. Differential diagnoses of dementia

    Vascular Dementia

    • Cognitive decline in the setting of cerebrovascular disease
    • Second leading cause of dementia
    • Suspected in the presence of long-standing hypertension or diabetes mellitus
    • Multiple small cerebral infarcts can result in the loss of cognitive function
    • CT and MRI show previous cerebral infarcts

    Frontotemporal Dementia (Pick Disease)

    • Focal atrophy of the frontal and temporal lobes on brain CT or MRI
    • Deposition of tau protein in the brain (Pick bodies)
    • Most commonly affects males over 60 years old
    • Language and behavior become abnormal first
    • Memory is preserved until later stages

    Lewy Body Dementia

    • Dementia in the presence of parkinsonian signs:
    • Resting tremor
    • Shuffling gait
    • Fluctuations in cognitive function with periods of alertness and attention
    • Visual hallucinations in more than 75% of cases

    Huntington Disease

    • Autosomal dominant degenerative disorder of adult onset
    • Movement disorders, neuropsychiatriс manifestations, and dementia

    Creutzfeldt-Jakob Disease

    • A spongiform encephalopathy
    • Rapidly progressive dementia following infection with prion proteins

    Other causes of dementia are those known as reversible causes these can be related to alcohol and medication intake or metabolic disorders such as vitamin B-12 deficiency, thyroid disease, hyponatremia, hypercalcemia and hepatic and renal dysfunction.

    Detection and subsequent correction of these conditions may lead to reversal of dementia symptoms making their early diagnosis critically important another cause of reversible dementia is normal pressure hydrocephalus.

    Normal Pressure Hydrocephalus

    • Most commonly affects elderly males
    • Clinical triad:
      • Dementia
      • Gait disturbances
      • Urinary incontinence = “Wacky, Wobbly and Wet”
    • CT and MRI show enlarged cerebral ventricles

    Alzheimer Disease

    • Neurodegenerative disorder of unknown cause
    • Primarily presents in patients over 65 years of age
    • Most common cause of dementia (70% of cases)

    2. Clinical manifestations of Alzheimer disease

    Memory Impairment

    • First clinical manifestation is memory impairment in the form of anterograde episodic amnesia
    • Characteristic pattern of memory impairment:
      • Early loss of recent memory (hippocampus)
      • Immediate, distant, and procedural memory are preserved until later stages of disease
    • Other forms of cognitive impairment:
      • Language and visuospatial skills are affected first
      • Behavioral and executive dysfunction appear later
      • Apraxia manifests as the inability to perform learned motor tasks

    Executive Dysfunction

    • Poor judgment, poor planning, or poor insight
      • Anosognosia, or loss of insight into one’s own disorder, is characteristic of Alzheimer disease
      • Patients trivialize severity of their condition

    Later Stages

    • Neuropsychiatrie manifestations:
      • Changes in personality
      • Aggression
      • Agitation
      • Psychosis
    • 30% of patients suffer from depression
    • Focal neurologic deficits may appear

    3. Diagnosis of Alzheimer disease

    • There is no diagnostic test for Alzheimer disease
    • Diagnosis must be made clinically once all other causes of dementia have been excluded
    • Exclusion tests include:
      • Complete blood count
      • Electrolyte panel
      • Levels of thyroid hormone, liver enzymes, vitamin B-12
      • RPR (rapid plasma reagin) is a screening test for syphilis
      • HIV ELISA
      • Brain CT, MRI
    • Usually confirmed postmortem, following autopsy and histopathologic examination of the patient’s brain tissue

    4. Pathologic features of Alzheimer disease

    • The pathogenesis of Alzheimer disease is unknown
    • Microscopic findings characteristic of Alzheimer disease are not pathognomonic for it:
      • Neurofibrillary tangles
      • Senile plaques
      • Granulovacuolar degeneration
      • Amyloid angiopathy of small to medium-sized brain vessels
    • Macroscopic findings:
      • Diffuse cerebral and/or cortical atrophy
      • Hippocampal atrophy

    Neurofibrillary Tangles

    • Made of phosphoryiated tau protein:
      • A stabilizer of microtubules found in neurons
      • When phosphoryiated, forms insoluble intraneuronal inclusions:
        • Interfere with proper functioning
        • Lead to neuronal degeneration
    • Most prominent in the hippocampal region
    • Neurofibrillary tangle count strongly correlates with disease severity
    Alzheimer disease, Alzheimer, manifestations of Alzheimer's disease, diagnosis of Alzheimer's disease, what is Alzheimer disease, features of Alzheimer's disease, pathology of Alzheimer disease, Alzheimer disease in Down syndrome, treatment of Alzheimer disease, Clinical presentation of Alzheimer disease, dementia, dementia diagnosis, Vascular dementia, Frontotemporal dementia, Pick disease, Creutzfeldt-Jakob disease, Huntington disease

    Senile Plaques

    • Composed of beta-amyloid deposits in the extracellular brain matter
    • A small number of plaques can be a physiologic finding as a result of the normal aging process
    • A large number of plaques is consistent with Alzheimer disease
    • Mutations in certain genes could be responsible for the increased deposition of amyloid protein:
      • Amyloid precursor protein (APP) gene (chromosome 21)
      • Presenilin 1 gene (chromosome 14)
      • Presenilin 2 gene (chromosome 1)
    Alzheimer disease, Alzheimer, manifestations of Alzheimer's disease, diagnosis of Alzheimer's disease, what is Alzheimer disease, features of Alzheimer's disease, pathology of Alzheimer disease, Alzheimer disease in Down syndrome, treatment of Alzheimer disease, Clinical presentation of Alzheimer disease, dementia, dementia diagnosis, Vascular dementia, Frontotemporal dementia, Pick disease, Creutzfeldt-Jakob disease, Huntington disease

    Alzheimer Disease in Down Syndrome

    • The role of chromosome 21 in the production of amyloid precursor protein has been speculated to contribute to the high prevalence of Alzheimer disease in people with trisomy 21
    • Down syndrome patients are known to develop Alzheimer disease in their forties, 15-20 years before the general population

    5. Treatment of Alzheimer disease

    No cure for Alzheimer disease, but early treatment has been shown to slow progression.

    Cholinesterase Inhibitors

    • Cholinestrase inhibitors (donepezil) are indirect-acting cholinomimetics:
      • Prevent the breakdown of acetylcholine in the synaptic cleft
    • Acetylcholine is a neurotransmitter involved in synaptic plasticity:
      • Allows for synapses to change, thereby allowing for learning and memory
    • Patients have a marked reduction in the activity of choline acetyltransferase in the cerebral cortex and hippocampus
    • By increasing the amount of acetylcholine available in neural junctions, cholinesterase inhibitors are thought to slow the progression of neuronal degeneration

    NMDA Receptor Antagonist (Memantine)

    • The N-methyl-D-aspartate (NMDA) receptor:
      • Involved in learning and memory
      • Found abundantly within hippocampal and cortical neurons
    • Glutamate:
      • The main excitatory neurotransmitter acting on these neurons
      • Activates the NMDA receptor by increasing the flow of cations through non-selective channels
      • Excessive stimulation of the NMDA receptor by glutamate can result in neurotoxicity
    • Memantine:
      • Thought to block excessive activity of the NMDA receptor while preserving its normal functions (neuroprotective effect)
      • Used in combination with cholinesterase inhibitors

    Mood Stabilizers

    • Antidepressants, valproic acid, and other mood stabilizers can also prove useful in the treatment of Alzheimer disease

    CT or MRI in patients with Alzheimer disease

    Alzheimer disease, Alzheimer, manifestations of Alzheimer's disease, diagnosis of Alzheimer's disease, what is Alzheimer disease, features of Alzheimer's disease, pathology of Alzheimer disease, Alzheimer disease in Down syndrome, treatment of Alzheimer disease, Clinical presentation of Alzheimer disease, dementia, dementia diagnosis, Vascular dementia, Frontotemporal dementia, Pick disease, Creutzfeldt-Jakob disease, Huntington disease


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    ]]> The Hamilton Anxiety Rating Scale (HAM-A/HARS) online calculator https://clincasequest.hospital/ham-ahars/ Fri, 21 Jan 2022 07:10:54 +0000 https://clincasequest.hospital/?p=32908 The Hamilton Anxiety Rating Scale evaluates anxiety levels based on clinical questions, quantifies the severity of anxiety syndrome, and is often used to evaluate antipsychotic…

    Сообщение The Hamilton Anxiety Rating Scale (HAM-A/HARS) online calculator появились сначала на ClinCaseQuest.

    ]]>     The Hamilton Anxiety Rating Scale evaluates anxiety levels based on clinical questions, quantifies the severity of anxiety syndrome, and is often used to evaluate antipsychotic drugs.

    It consists of 14 indicators, each of which is defined by several symptoms. Each indicator is rated on a 5-point scale from 0 (none) to 4 (severe). The Hamilton Anxiety Scale can help objectify and rate the severity of a patient’s anxiety.

    Loading...
    Points total 0
    * Required

    The Hamilton Anxiety Scale can help objectify and assess the severity of a patient’s anxiety.

    Each parameter is assessed according to the level of severity:

    Point Values:

    0=Not Present
    +1=Mild
    +2=Moderate
    +3=Severe
    +4=Very Severe

    To assess the Hamilton anxiety scale, it is necessary to add the selected points.

    1. Anxious mood: Worries, anticipation of the worst, fearful anticipation, irritability.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    2. Tension: Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    3. Fears: Of dark, of strangers, of being left alone, of animals, of traffic, of crowds.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    4. Insomnia: Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    5.  Intellectual: Difficulty in concentration, poor memory.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    6. Depressed mood: Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    7. Somatic (muscular): Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    8. Somatic (sensory): Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, pricking sensation.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    9. Cardiovascular symptoms: Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    10 . Respiratory symptoms: Pressure or constriction in chest, choking feelings, sighing, dyspnea.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    11. Gastrointestinal symptoms: Difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    12. Genitourinary symptoms: Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation,loss of libido, impotence.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    13. Autonomic symptoms: Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4
    14. Behavior at interview: Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc.Not Present0
     Mild+1
     Moderate+2
     Severe+3
     Very Severe+4

    Score interpretation:

    • Scores ≤17 indicate mild anxiety severity.
    • Scores of 18-24 indicate mild to moderate anxiety severity
    • Scores of 25-30 indicate moderate to severe anxiety severity
    • Scores >30 indicate severe anxiety

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    Literature:

    1. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959; 32:50–55 https://pubmed.ncbi.nlm.nih.gov/13638508/
    2. Maier W, Buller R, Philipp M, Heuser I. The Hamilton Anxiety Scale: reliability, validity and sensitivity to change in anxiety and depressive disorders. J Affect Disord 1988;14(1):61–8 https://pubmed.ncbi.nlm.nih.gov/2963053/  Per Bech. Measuring States of
    3. Anxiety with Clinician-Rated and Patient-Rated Scales, Different Views of Anxiety Disorders. 2011, DOI: 10.5772/21246 https://www.intechopen.com/books/different-views-of-anxiety-disorders/measuring-states-of-anxiety-with-clinician-rated-and-patient-rated-scales

    Charlson Comorbidity Index (CCI) Online Calculator

    Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

    Loading...

    History of definite or probable MI (EKG changes and/or enzyme changes)

    Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

    Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

    History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

    Chronic cognitive deficit

    Any history of treatment for ulcer disease or history of ulcer bleeding

    Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

    Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

    * Required
    VariablePointsAge <50…
    Read More

    Multiple Myeloma Diagnostic Criteria – Online Calculator

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    ≥1 of the following (A or B)

    ≥1 myeloma defining event (C1 or C2)

    * Required
    For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
    Read More


    Сообщение The Hamilton Anxiety Rating Scale (HAM-A/HARS) online calculator появились сначала на ClinCaseQuest.

    ]]>         ABCD2 Score System for stroke risk assessment after suspected TIA, online calculator https://clincasequest.hospital/abcd2-score-stroke-risk/ Wed, 14 Jul 2021 11:39:00 +0000 https://clincasequest.hospital/?p=29794 ABCD2 Score System estimates the risk of stroke after a suspected transient ischemic attack (TIA). The ABCD2 score can help physicians to provide risk stratification stroke…

    Сообщение ABCD2 Score System for stroke risk assessment after suspected TIA, online calculator появились сначала на ClinCaseQuest.

    ]]>     ABCD2 Score System estimates the risk of stroke after a suspected transient ischemic attack (TIA). The ABCD2 score can help physicians to provide risk stratification stroke in patients presenting with a TIA. Patients with a low risk of stroke could undergo outpatient diagnostic tests. Patients with moderate and high risk should be hospitalized for careful diagnosis.

    Age ≥ 60 years:
    No
    Yes

    BP ≥ 140/90 mmHg Initial BP. Either SBP ≥ 140 or DBP ≥ 90:
    No
    Yes

    Clinical features of the TIA:
    Unilateral weakness
    Speech disturbance without weakness
    Other symptoms

    Duration of symptoms:
    <10 minutes
    10-59 minutes
    ≥ 60 minutes

    History of diabetes:
    Yes
    No


    Patient’s score Range Risk group Stroke Risk Recommendation
    0 0 0 0 0

    The addition of the selected points is required.

    CriteriaValuePoints
    Age ≥ 60 yearsY/N+1
    BP ≥ 140/90 mmHgY/N+1
    Clinical features of the TIAUnilateral Wwakness+2
     Speech disturbance without weakness+1
     Other symptoms0
    Duration of symptoms< 10 minutes0
     10-59 minutes+1
     ≥ 60 minutes+2
    History of diabetesY/N+1

    Multiple studies have shown that as the ABCD2 score increases the risk of a subsequent stroke also increases.

    Results:

    Total scoreRisk groupStroke Risk
    		Recommendation
    0-3Low Risk• 2-Day Stroke Risk: 1.0%
    • 7-Day Stroke Risk: 1.2%
    • 90-Day Stroke Risk: 3.1%      		• Arrange expedited evaluation as an outpatient with the goal of obtaining the relevant studies and consultations within 24 hours.
    • Consider further imaging modalities including MRI and carotid ultrasound as outpatient.
    • Consider consulting Neurology to help determine whether the patient would benefit from further inpatient evaluation or to expedite outpatient follow-up when appropriate.      
    4-5Moderate Risk• 2-Day Stroke Risk: 4.1%
    • 7-Day Stroke Risk: 5.9%
    • 90-Day Stroke Risk: 9.8%    		• Admit patient for further evaluation to the hospital.
    • Consult Neurology.
    • Consider obtaining an MRI and other appropriate vascular and embolic imaging.    
    6-7High Risk• 2-Day Stroke Risk: 8.1%
    • 7-Day Stroke Risk: 11.7%
    • 90-Day Stroke Risk: 17.8%    		• Admit patient for further evaluation to the hospital.
    • Consult Neurology.
    • Consider obtaining an MRI and other appropriate vascular and embolic imaging.    
    • A prospective observational study of 637 patients presenting to the ED found that the ABCD2 score did not add incremental value beyond an ED evaluation that included central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in the study’s cohort. (Stead 2010)
    • In this population of patients with TIA patients, a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, found that the rate of stroke was independent of ABCD2 risk stratification. (Stead 2010)

    Limitations:

    The ABCD2 score should not be used as a substitute for clinical judgement or decision making. The ABCD score was developed in an outpatient setting (not in emergency departments!). It has been shown to have lower accuracy when ABCD2 score used by non-specialists (primary care or emergency physicians).

    Patients with a low baseline risk of stroke (≤ 2%) with a low ABCD2 score (0-2) are at low risk for having a stroke within the next 7 days (0.4-0.8%). In this population of patients with TIA patients, rapid emergency department-based outpatient diagnostic tests are recommended.

    In centers where computed tomography and carotid ultrasound studies are performed in collaboration with a stroke service, adding assessment based on the ABCD2 score to the evaluation appears unnecessary.

    Based on the the poor performance of the ABCD2 score system in the emergency department setting, combined with difficulties in arranging the necessary imaging and specialty follow-up within 24-hour window, that most emergency department physicians were likely to choose to perform a rapid evaluation of TIA patients (imaging, possible neurology consultation) regardless of the ABCD2 score.

    Literature
    Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007 Jan 27;369(9558):283-92. https://pubmed.ncbi.nlm.nih.gov/17258668/
    Josephson SA, Sidney S, Pham TN, Bernstein AL, Johnston SC. Higher ABCD2 score predicts patients most likely to have true transient ischemic attack. Stroke. 2008 Nov;39(11):3096-8. doi: 10.1161/STROKEAHA.108.514562. Epub 2008 Aug 7. https://pubmed.ncbi.nlm.nih.gov/18688003/
    Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN, Warlow CP, Mehta Z. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet. 2005 Jul 2-8;366(9479):29-36. https://pubmed.ncbi.nlm.nih.gov/15993230/
    Sanders LM, Srikanth VK, Blacker DJ, Jolley DJ, Cooper KA, Phan TG.Performance of the ABCD2 score for stroke risk post TIA: meta-analysis and probability modeling. Neurology. 2012 Sep 4;79(10):971-80. doi: 10.1212/WNL.0b013e31825f9d02. Epub 2012 Jun 13. PubMed PMID: 22700810. https://pubmed.ncbi.nlm.nih.gov/22700810/
    Stead LG, Suravaram S, Bellolio MF, Enduri S, Rabinstein A, Gilmore RM, Bhagra A, Manivannan V, Decker WW. An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack. Ann Emerg Med. 2011 Jan;57(1):46-51. doi: 10.1016/j.annemergmed.2010.07.001. Epub 2010 Sep 19. PubMed PMID: 20855130. https://pubmed.ncbi.nlm.nih.gov/20855130/
    Perry JJ, Sharma M, Sivilotti ML, Sutherland J, Symington C, Worster A, Émond M, Stotts G, Jin AY, Oczkowski WJ, Sahlas DJ, Murray HE, MacKey A, Verreault S, Wells GA, Stiell IG. Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack. CMAJ. 2011 Jul 12;183(10):1137-45. doi: 10.1503/cmaj.101668. Epub 2011 Jun 6. PubMed PMID: 21646462. https://pubmed.ncbi.nlm.nih.gov/21646462/

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    ]]>         The Glascow Coma Scale https://clincasequest.hospital/glascow-coma/ Sat, 26 Jun 2021 07:07:56 +0000 https://clincasequest.hospital/?p=29303 The Glascow Coma Scale, GCS is a scale for assessing impaired consciousness and coma in children older than 4 years and adults. On the scale,…

    Сообщение The Glascow Coma Scale появились сначала на ClinCaseQuest.

    ]]>     The Glascow Coma Scale, GCS is a scale for assessing impaired consciousness and coma in children older than 4 years and adults.

    On the scale, the condition is assessed by the sum of points based on three parameters: Eye response (E – from 1 to 4), Verbal response (V – from 1 to 5) and Motor response (M – from 1 to 6). Thus, the minimum number of points is 3 (third degree coma), the maximum is 15 (clear consciousness).

    Registration time:


    Eye response, E:
    Spontaneously
    To verbal command
    To pain
    No eye opening

    Verbal response, V:
    Oriented
    Confused
    Inappropriate words
    Incomprehensible sounds
    No verbal response

    Motor response, M:
    Obeys commands
    Localizes pain
    Withdrawal from pain
    Flexion to pain
    Extension to pain
    No motor response


    Patient’s score Patient’s assessment Level of consciousness
    0 0 0
    ParameterResponsePoints
    Eye response, ESpontaneously4
    To verbal command3
    To pain2
    No eye opening1
    Verbal response, VOriented5
    Confused4
    Inappropriate words3
    Incomprehensible sounds2
    No verbal response1
    Motor response, MObeys commands6
     Localizes pain5
     Withdrawal from pain4
     Flexion to pain3
     Extension to pain2
     No motor response1

    In the Glasgow scale, clinical signs are differentiated according to their severity, which is reflected in points. To obtain information about the degree of change in consciousness, the points are summed up. The greater the sum of points, the less the degree of inhibition of brain function, and on the contrary – the less this sum, the deeper the coma.

    Levels of consciousnessGCS (in points)
    Consciousness is clear15
    Moderate stun13-14
    Deep stun11-12
    Sopor9-10
    Coma I degree7-8
    Coma II degree5-6
    Coma III degree3-4

    GCS  designed for use in serial assessments of patients with coma from either medical or surgical causes. The GCS is commonly used in the pre-hospital and acute care setting as well as during hospitalization to evaluate mental status in both traumatic and non-traumatic clinical presentations.

    In the care of an individual patient, the ratings of the three criteria in the Scale should be assessed, monitored, reported, and communicated separately.

    The combined Score is an index of the severity impairment and is useful as a summary of a patient’s condition, in classifying groups of different severity and for triage. The Score cannot be calculated if one or other of the component criteria is not testable.

    The GCS has been shown to have statistical correlation with a broad array of adverse neurologic outcomes, including brain injury, need for neurosurgery, impaired recovery and mortality.

    Besides, the GCS has been incorporated into numerous guidelines and assessment scores (e.g. ACLS, ATLS, APACHE I-III, TRISS and WNS SAH Grading Scale).

    In some patients, it may be impossible to assess one or more of the three components of the coma scale. The reasons include the next, but are not limited to:

    • Eye: local injury and/or edema.
    • Verbal: intubation.
    • All (eye, verbal, motor): sedation, paralysis, and ventilation eliminating all responses. 

    If a component is untestable, a score of 1 should not be assigned. In this circumstance, summation of the findings into a total Glasgow Coma Score is invalid.

    The 3 parts of the Glasgow Coma Scale are charted independently, and the position can be recorded as “NT” (not testable or not applicable –“NA”), with an option of indicating the reason, e.g. “C” for eye closure and “T” for intubation

    The GCS score can be indicative of how critically ill a patient is.

    Trauma patients presenting with GCS <15 warrant close attention and reassessment.

    A declining GCS is concerning in any setting and should prompt assessment of the airway and possible intervention.

    Conversely, a GCS of 15 should not be taken as an indication that a patient (trauma or medical) is not critically ill. Decisions about the aggressiveness of the management and treatment plans should be made based on clinical presentation and context and not in any way overridden by the GCS score.

    Clinical management decisions should not be based solely on the GCS score in the acute setting.

    If a trauma patient has a GCS ≤8 and there is clinical concern that they are unable to protect their airway or that they have an expected worsening clinical course based on exam or imaging findings, then intubation can be considered.

    In any patient, a rapidly declining or waxing and waning GCS is concerning and intubation should be considered in the context of the patient’s overall clinical condition.

    Clinical management decisions should not be based solely on the GCS score in the acute setting.

    The Glasgow scale is usually written in this form: “GCS 8 = E1 V4 M3 at 07:35“.

    For more information on assessing a patient on the Glasgow Coma Scale, visit the official website. https://www.glasgowcomascale.org/

    LITERATURE:
    Teasdale G, Jennett B.Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4 https://pubmed.ncbi.nlm.nih.gov/4136544/
    Moore L, Lavoie A, Camden S, Le Sage N, Sampalis JS, Bergeron E, Abdous B. Statistical validation of the Glasgow Coma Score.J Trauma. 2006 Jun;60(6):1238-43; discussion 1243-4 https://pubmed.ncbi.nlm.nih.gov/16766966/
    “Reith FC, Van den brande R, Synnot A, Gruen R, Maas AI. The reliability of the Glasgow Coma Scale: a systematic review. Intensive Care Med. 2016;42(1):3-15 https://pubmed.ncbi.nlm.nih.gov/26564211/
    Teasdale G, Jennett B. Assessment of coma and severity of brain damage. Anesthesiology. 1978;49:225-226 https://pubmed.ncbi.nlm.nih.gov/686455/
    Teasdale G, Jennett B, Murray L, Murray G. Glasgow coma scale: to sum or not to sum. Lancet. 1983 Sep 17;2(8351):678 https://pubmed.ncbi.nlm.nih.gov/6136811/
    Healey C, Osler TM, Rogers FB, Healey MA, Glance LG, Kilgo PD, Shackford SR, Meredith JW. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma. 2003 Apr;54(4):671-8; discussion 678-80 https://pubmed.ncbi.nlm.nih.gov/12707528/
    Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011 Nov;58(5):427-30. doi: 10.1016/j.annemergmed.2011.06.009. Epub 2011 Jul 30 https://pubmed.ncbi.nlm.nih.gov/21803447/
    Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australas Emerg Nurs J. 2012 Aug;15(3):170-83. doi: 10.1016/j.aenj.2012.06.002. Epub 2012 Aug 3. Review https://pubmed.ncbi.nlm.nih.gov/22947690/
    Yeh DD. Glasgow Coma Scale 40 years later: in need of recalibration? JAMA Surg. 2014 Jul;149(7):734. doi: 10.1001/jamasurg.2014.47. No abstract available https://pubmed.ncbi.nlm.nih.gov/24899079/
    Teasdale G. Forty Years on: Updating the Glasgow Coma Scale. Nursing Times. 2014; 110(42) https://cdn.ps.emap.com/wp-content/uploads/sites/3/2014/10/141015Forty-years-on-updating-the-Glasgow-coma-scale.pdf
    Gill M, Windemuth R, Steele R, Green SM. A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Ann Emerg Med. 2005 Jan;45(1):37-42 https://pubmed.ncbi.nlm.nih.gov/15635308/
    Haukoos JS, Gill MR, Rabon RE, Gravitz CS, Green SM. Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma. Ann Emerg Med. 2007 Jul;50(1):18-24. Epub 2006 Nov 16 https://pubmed.ncbi.nlm.nih.gov/17113193/
    Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011 Nov;58(5):417-25. doi: 10.1016/j.annemergmed.2011.05.033. Epub 2011 Jul 30 https://pubmed.ncbi.nlm.nih.gov/21803448/
    Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol. 2014;13(8):844-54 https://pubmed.ncbi.nlm.nih.gov/25030516/

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    ]]>         Mortality SCORE for COVID-19: on-line calculator https://clincasequest.hospital/on-line-calculator-mortality-score-for-covid-19/ Thu, 20 May 2021 20:25:42 +0000 https://clincasequest.hospital/?p=29099 Mortality risk calculator for hospitalized patients diagnosed with COVID-19. 4C MORTALITY SCORE FOR COVID-19 This scale was developed specifically for hospitalized patients with COVID-19. This…

    Сообщение Mortality SCORE for COVID-19: on-line calculator появились сначала на ClinCaseQuest.

    ]]>     Mortality risk calculator for hospitalized patients diagnosed with COVID-19. 4C MORTALITY SCORE FOR COVID-19

    This scale was developed specifically for hospitalized patients with COVID-19. This may not apply to outpatients. Stratification of the risk of death in hospitalized patients with COVID-19 is important for further decision-making on treatment tactics and predicting the course of the disease.

    Age:

    Sex at birth:
    Male
    Female

    Number of comorbidities:

    Respiratory rate, breaths/min:
    <20
    20–29
    ≥30

    Peripheral oxygen saturation on room air:
    ≥92%
    <92%

    Glasgow Coma Scale:
    15
    <15

    Urea or BUN:
    Urea <7 mmol/L (<42 mg/dL) OR BUN <19.6 mg/dL
    Urea ≥7 to ≤14 mmol/L (≥42mg/dL to ≤84 mg/dL) OR BUN ≥19.6 to ≤39.2 mg/dL
    Urea >14 mmol/L (>84 mg/dL) OR BUN >39.2 mg/dL

    C-reactive protein, mg/L:
    <50 mg/L (<5 mg/dL)
    50-99 mg/L (5-9.9 mg/dL)
    ≥100 mg/L (≥10 mg/dL)



    Mortality Score Risk group In-hospital mortality
    0 0 0

    To assess the risk of mortality in hospitalized patients diagnosed with COVID-19 is required a preliminary assessment of the state of consciousness on the Glasgow scale.

    Following the Glasgow scale, the following parameters are assessed to assess the mortality rate from 4C:

     VariablePoints
    Age, years<500
     50-592
     60-694
     70-796
     ≥807
    Sex at birthFemale0
     Male1
    Number of comorbidities*00
     11
     ≥22
    Respiratory rate, breaths/min<200
     20-291
     ≥302
    Peripheral oxygen saturation on room air≥92%0
     <92%2
    Glasgow Coma Scale150
     <152
    Urea or BUN (use measurement available)Urea <7 mmol/L (<42 mg/dL) OR  BUN <19.6 mg/dL0
     Urea ≥7 to ≤14 mmol/L (≥42mg/dL to ≤84 mg/dL) OR BUN ≥19.6 to ≤39.2 mg/dL1
     Urea >14 mmol/L (>84 mg/dL) OR BUN >39.2 mg/dL3
    C-reactive protein, mg/L<50 mg/L (<5 mg/dL)0
     50-99 mg/L (5-9.9 mg/dL)1
     ≥100 mg/L (≥10 mg/dL)2

    *Comorbidities include chronic cardiac disease, chronic respiratory disease (excluding asthma), chronic renal disease (estimated glomerular filtration rate ≤30), mild to severe liver disease, dementia, chronic neurological conditions, connective tissue disease, diabetes mellitus (diet, tablet, or insulin controlled), HIV or AIDS, and malignancy.

    Interpretation:

    4C Mortality ScoreRisk groupIn-hospital mortality
    0-3Low 1.2-1.7%
    4-8Intermediate9.1-9.9%
    9-14High31.4-34.9%
    ≥15Very high61.5-66.2%
    • Low risk – May be suitable for outpatient management
    • Intermediate risk – May be suitable for general inpatient treatment
    • High risk – May require aggressive treatment and higher level of monitoring

     

    Apply to risk stratify patients who are admitted with COVID-19.

    Designed specifically for hospitalized COVID-19 patients. This may not apply to patients seen in the outpatient setting.

    Requires eight specific predictors of mortality, not all of which may be immediately available in all settings (e.g., CRP).  

    Patient population in the study had a median age of 73 years old, 82% white, with an overall mortality of 32.2%. All patients were from England, Scotland, and Wales. Consider when applying this to your patient population.

    Not externally validated and may lead to unknown applicability and generalizability.

    Risk stratification of admitted COVID-19 patients to aid in determining mortality risk, decision for level of care, and prognostication.

    The 4C Mortality Score was derived from a prospective observational cohort study based upon positively tested COVID-19 patients admitted to 260 hospitals in England, Scotland and Wales. The score includes eight variables consisting of age, sex, number of comorbidities, respiratory rate, peripheral oxygen saturation, Glasgow coma scale score, urea level, and C-reactive protein. The score, ranging from 0-21, predicts in-hospital mortality from low risk to very high risk. The score, when compared against existing scores for CAP and COVID-19, performed better in predicting in-hospital mortality in the validation cohort.

    Although the score performed well in the internal validation of the study, it requires external validation. The score is limited to determining in-patient hospital mortality and is not designed to be applicable to the outpatient setting. Overall generalizability of the score needs to be further investigated as it was derived and validated in a primarily homogeneous ethnic and age cohort.

    Eight specific predictors of mortality are required, not all of which may be available in all settings at once (eg, C-reactive protein).

    The median age of patients in the study was 73 years, 82% were Caucasian, with an overall mortality rate of 32.2% in the group. All patients were from England, Scotland and Wales.

    Be careful, this scale has not been externally validated at this time. Use with care!

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    ]]>