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358

Cranial Nerve Examination - Abnormal

Cranial Nerve 1- Olfaction This patient has difficulty identifying the smells presented. Loss of smell is anosmia. The most common cause is a cold (as in this patient) or nasal allergies. Other causes include trauma or a meningioma affecting the olfactory tracts. Anosmia is also seen in Kallman syndrome because of agenesis of the olfactory bulbs. Cranial Nerve 2- Visual acuity This patientâs visual acuity is being tested with a Rosenbaum chart. First the left eye is tested, then the right eye. He is tested with his glasses on so this represents corrected visual acuity. He has 20/70 vision in the left eye and 20/40 in the right. His decreased visual acuity is from optic nerve damage. Cranial Nerve II- Visual field The patient's visual fields are being tested with gross confrontation. A right sided visual field deficit for both eyes is shown. This is a right hemianopia from a lesion behind the optic chiasm involving the left optic tract, radiation or striate cortex. Cranial Nerve II- Fundoscopy The first photograph is of a fundus showing papilledema. The findings of papilledema include 1. Loss of venous pulsation 2. Swelling of the optic nerve head so there is loss of the disc margin 3. Venous engorgement 4. Disc hyperemi 5. Loss of the physiologic cup an 6. Flame shaped hemorrhages. This photograph shows all the signs except the hemorrhages and loss of venous pulsations. The second photograph shows optic atrophy, which is pallor of the optic disc resulting form damage to the optic nerve from pressure, ischemia, or demyelination. Images Courtesy Dr. Kathleen Digre, University of Uta Cranial Nerves 2 & 3- Pupillary Light Refle The swinging flashlight test is used to show a relative afferent pupillary defect or a Marcus Gunn pupil of the left eye. The left eye has perceived less light stimulus (a defect in the sensory or afferent pathway) then the opposite eye so the pupil dilates with the same light stimulus that caused constriction when the normal eye was stimulated. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Inspection & Ocular Alignmen This patient with ocular myasthenia gravis has bilateral ptosis, left greater than right. There is also ocular misalignment because of weakness of the eye muscles especially of the left eye. Note the reflection of the light source doesn't fall on the same location of each eyeball. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Versions • The first patient shown has incomplete abduction of her left eye from a 6th nerve palsy. • The second patient has a left 3rd nerve palsy resulting in ptosis, dilated pupil, limited adduction, elevation, and depression of the left eye. Second Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Duction Each eye is examined with the other covered (this is called ductions). The patient is unable to adduct either the left or the right eye. If you watch closely you can see nystagmus upon abduction of each eye. When both eyes are tested together (testing versions) you can see the bilateral adduction defect with nystagmus of the abducting eye. This is bilateral internuclear ophthalmoplegia often caused by a demyelinating lesion effecting the MLF bilaterally. The adduction defect occurs because there is disruption of the MLF (internuclear) connections between the abducens nucleus and the lower motor neurons in the oculomotor nucleus that innervate the medial rectus muscle. Saccades Smooth Pursui The patient shown has progressive supranuclear palsy. As part of this disease there is disruption of fixation by square wave jerks and impairment of smooth pursuit movements. Saccadic eye movements are also impaired. Although not shown in this video, vertical saccadic eye movements are usually the initial deficit in this disorder. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Utah Optokinetic Nystagmu This patient has poor optokinetic nystagmus when the tape is moved to the right or left. The patient lacks the input from the parietal-occipital gaze centers to initiate smooth pursuit movements therefore her visual tracking of the objects on the tape is inconsistent and erratic. Patients who have a lesion of the parietal-occipital gaze center will have absent optokinetic nystagmus when the tape is moved toward the side of the lesion. Vestibulo-ocular refle The vestibulo-ocular reflex should be present in a comatose patient with intact brainstem function. This is called intact "Doll’s eyes" because in the old fashion dolls the eyes were weighted with lead so when the head was turned one way the eyes turned in the opposite direction. Absent "Doll’s eyes" or vestibulo-ocular reflex indicates brainstem dysfunction at the midbrain-pontine level. Vergenc Light-near dissociation occurs when the pupils don't react to light but constrict with convergence as part of the near reflex. This is what happens in the Argyll-Robertson pupil (usually seen with neurosyphilis) where there is a pretectal lesion affecting the retinomesencephalic afferents controlling the light reflex but sparing the occipitomesencephalic pathways for the near reflex. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerve 5- Sensor There is a sensory deficit for both light touch and pain on the left side of the face for all divisions of the 5th nerve. Note that the deficit is first recognized just to the left of the midline and not exactly at the midline. Patients with psychogenic sensory loss often identify the sensory change as beginning right at the midline. Cranial Nerves 5 & 7 - Corneal refle A patient with an absent corneal reflex either has a CN 5 sensory deficit or a CN 7 motor deficit. The corneal reflex is particularly helpful in assessing brainstem function in the unconscious patient. An absent corneal reflex in this setting would indicate brainstem dysfunction. Cranial Nerve 5- Motor • The first patient shown has weakness of the pterygoids and the jaw deviates towards the side of the weakness. • The second patient shown has a positive jaw jerk which indicates an upper motor lesion affecting the 5th cranial nerve. First Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 7- Motor • The first patient has weakness of all the muscles of facial expression on the right side of the face indicating a lesion of the facial nucleus or the peripheral 7th nerve. • The second patient has weakness of the lower half of his left face including the orbicularis oculi muscle but sparing the forehead. This is consistent with a central 7th or upper motor neuron lesion. Video Courtesy of Alejandro Stern, Stern Foundatio Cranial Nerve 7- Sensory, Tast The patient has difficulty correctly identifying taste on the right side of the tongue indicating a lesion of the sensory limb of the 7th nerve. Cranial Nerve 8- Auditory Acuity, Weber & Rinne Test This patient has decreased hearing acuity of the right ear. The Weber test lateralizes to the right ear and bone conduction is greater than air conduction on the right. He has a conductive hearing loss. Cranial Nerve 8- Vestibula Patients with vestibular disease typically complain of vertigo – the illusion of a spinning movement. Nystagmus is the principle finding in vestibular disease. It is horizontal and torsional with the slow phase of the nystagmus toward the abnormal side in peripheral vestibular nerve disease. Visual fixation can suppress the nystagmus. In central causes of vertigo (located in the brainstem) the nystagmus can be horizontal, upbeat, downbeat, or torsional and is not suppressed by visual fixation. Cranial Nerve 9 & 10- Moto When the patient says "ah" there is excessive nasal air escape. The palate elevates more on the left side and the uvula deviates toward the left side because the right side is weak. This patient has a deficit of the right 9th & 10th cranial nerves. Video Courtesy of Alejandro Stern, Stern Foundatio Cranial Nerve 9 & 10- Sensory and Motor: Gag Refle Using a tongue blade, the left side of the patient's palate is touched which results in a gag reflex with the left side of the palate elevating more then the right and the uvula deviating to the left consistent with a right CN 9 & 10 deficit. Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 11- Moto When the patient contracts the muscles of the neck the left sternocleidomastoid muscle is easily seen but the right is absent. Looking at the back of the patient, the left trapezius muscle is outlined and present but the right is atrophic and hard to identify. These findings indicate a lesion of the right 11th cranial nerve. Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 12- Moto Notice the atrophy and fasciculation of the right side of this patient's tongue. The tongue deviates to the right as well because of weakness of the right intrinsic tongue muscles. These findings are present because of a lesion of the right 12th cranial nerve.  
Neurologic Exam
about 8 years ago
Preview
20
681

Cardiac conduction system and its relationship with ECG

The heart's conductions system controls the generation and propagation of electric signals or action potentials causing the hearts muscles to contract and the heart to pump blood.  
Nicole Chalmers
over 5 years ago
Preview
0
13

Alliance Contracting

Rural providers in NZ are being offered an opportunity to engage in health care planning under "Alliance contracts" - resources are needed to enable people to learn how to engage in this level of health governance.  
Joseph Scott-Jones
over 4 years ago
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0
10

Atos awarded contract for NHS records

Atos has been given the contract to extract patient records, MPs are told  
Telegraph.co.uk
about 5 years ago
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1
19

Hepatitis D

You can only contract this is you are also currently suffering from hepatitis B. You can get two types of infection: Normal co-existant infection – 90% of cases – this actually reduces the severity of the hep B infection! This is because infection with hepatitis D can reduce the replication rate of the hepatitis B virus. These people will usually make a full recovery from an unremarkable acute hepatitis.   
almostadoctor.com - free medical student revision notes
about 5 years ago
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0
14

Commissioning and funding general practice

Our report argues for a new approach that brings together funding for general practice with funding for many other services. This would entail new forms of commissioning, with GPs innovating in how care is delivered. As England’s population both expands and ages, so the demands on primary care will grow. Within the current commissioning and funding system innovative models of primary care provision are already being used. This report describes examples of these through four case studies in different areas of England. It also highlights how the existing system is imperfectly understood, particularly regarding contracts.  
kingsfund.org.uk
about 5 years ago
Www.bmj
1
16

Non-response bias versus response bias

Researchers used a postal questionnaire survey to investigate the career progression of NHS doctors. The questionnaire included details about past and current employment, future career plans, and when career milestones were reached. Analysis was confined to respondents working in the UK NHS (including those with an honorary NHS contract). The participants were all those who graduated from UK medical schools in 1977, 1988, and 1993. The questionnaire was sent to 10 344 graduates, of whom 7012 replied, giving a response rate of 68%.1  
bmj.com
about 5 years ago
Preview
1
23

Medical Student Podcast 003

Foundation Programme allocations (00:34), healthcare assistant university requirements (03:30), Ben Goldacre interview (07:08), student opinions on contract negotiations (13:38), #donatenominate (15:54)  
Audioboo
about 5 years ago
Preview
1
20

BMA - Home | British Medical Association

The British Medical Association (BMA) is the trade union and professional association for doctors and medical students in the UK. We negotiate doctors' contracts with the UK government and represent our members on the key issues that matter  
bma.org.uk
about 5 years ago
Preview
0
25

Commissioning and funding general practice

Our report argues for a new approach that brings together funding for general practice with funding for many other services. This would entail new forms of commissioning, with GPs innovating in how care is delivered. As England’s population both expands and ages, so the demands on primary care will grow. Within the current commissioning and funding system innovative models of primary care provision are already being used. This report describes examples of these through four case studies in different areas of England. It also highlights how the existing system is imperfectly understood, particularly regarding contracts.  
kingsfund.org.uk
about 5 years ago
Preview
6
386

Cardiac conduction system and its relationship with ECG‬

The heart's conductions system controls the generation and propagation of electric signals or action potentials causing the hearts muscles to contract and th...  
YouTube
almost 5 years ago
Preview
1
29

Medical Student Podcast 003

Foundation Programme allocations (00:34), healthcare assistant university requirements (03:30), Ben Goldacre interview (07:08), student opinions on contract negotiations (13:38), #donatenominate (15:54)  
audioBoom
over 4 years ago
Preview
1
63

Untitled Document

The specialized nodal and conducting cells of the heart are responsible for heartbeat. These specialized nodal and conducting cells tend to contract weakly because they contain very few contractile cells (myofibrils). What makes these cells unique is that they can easily generate an action potential (electrical impulse that causes the heart to beat) without the assistance of neurotransmitters or any nervous system input like any regular neurons. Along with these special properties of self-excitability, these cells can also rapidly conduct impulses to atrial and ventricular muscles. This explains why after death, the heart continues pumping because of the nodal and conducting cells; this is because the nodal and conducting cells are not hooked up with any neurotransmitters. Therefore, these specialized cells provide a self-excitatory system for the heart to generate impulses and a transmission system for rapid conduction of impulses in the heart.  
odec.ca
about 4 years ago
Www.bmj
1
19

Private firms enlisted to cut waiting lists for tests and surgery in £780m contract

Private firms have reached a deal potentially worth £780m (€1.1bn; $1.2bn) over four years to help NHS hospitals in England ease waiting times for surgery and diagnostic tests.  
bmj.com
about 4 years ago
Preview
1
31

In brief

Recruitment agent is sentenced for faking locum doctors’ experience: Ross Etherson, 34, has been sentenced to two years in prison, suspended for 12 months, for enhancing the CVs of doctors without their knowledge while working at the London recruitment firm Midas Medical Recruitment. Seven locum doctors (mostly applying for senior house officer posts) were employed in Lincoln and Sussex hospitals on the basis of Etherson’s misleading documents. There was no evidence that patients suffered clinically as a result of the fraud, and hospitals released the doctors from their contracts where necessary.  
bmj.com
about 4 years ago
Www.bmj
1
14

“Human guinea pig” asks for animal studies

A trial participant whose request for animal data had been rejected turned to Peter Gøtzsche for help. It later emerged that the information he requested didn’t exist at the start of the human trial. He describes what happened and says the social contract between patients and corporate sponsors of drug trials is broken  
bmj.com
about 4 years ago
Www.bmj
1
20

In brief

Recruitment agent is sentenced for faking locum doctors’ experience: Ross Etherson, 34, has been sentenced to two years in prison, suspended for 12 months, for enhancing the CVs of doctors without their knowledge while working at the London recruitment firm Midas Medical Recruitment. Seven locum doctors (mostly applying for senior house officer posts) were employed in Lincoln and Sussex hospitals on the basis of Etherson’s misleading documents. There was no evidence that patients suffered clinically as a result of the fraud, and hospitals released the doctors from their contracts where necessary.  
bmj.com
about 4 years ago
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0
88

The Arterial Highway

Metaphors and analogies have long been used to turn complex medical concepts into everyday ones, albeit with fancy terminology. Having been involved with many 3D animations on the topics of Blood Pressure, arteriosclerosis, cholesterol and the like, we find that often a metaphor goes a long way to building understanding, credibility and even compliance with patients. One of my favorite analogies is what we call the arterial highway. Much like their tarmacked counterparts, arteries act as conduits for all the parts that make your body go. A city typically uses highways, gas lines, water pipes, railways and other infrastructure to distribute important materials to its people. Your body is much the same, except that it does it all in one system, the cardiovascular system. This is used to deliver nutrients, extract waste, transport and deliver oxygen and even to maintain the temperature! The arteries can do all these things because of their smart three-layered structure. Our arteries consist of a muscular tube lined by smooth tissue. They have three layers named – the Adventitia, Media and Intima. Each is designed with a specific function and through the magic of evolution has developed to perform its function perfectly. The first is the Tunica Adventitia, or just adventitia. It is a strong outer covering over the arteries and veins. It has special tissues that are fibrous. The fibers let the arteries flex, expanding and contracting to accommodate changes in blood pressure as the blood flows past it. Unlike a steel pipe, arteries pulsate and so must be at once be flexible, and strong. Tunica Media - the middle layer of the walls of arteries and veins is made up of a smooth muscle with some elasticity built in. This layer expands and contracts in a rhythmic fashion, much like a Wave at a baseball game, as blood moves along it. The media layer is thicker in arteries than in veins, and importantly so, as arteries carry blood at a higher pressure than veins. The innermost layer of arteries and veins is the Tunica Intima. In arteries, this layer is composed of an elastic lining and smooth endothelium - a thin sheet of cells that form a type of skin over the surface. The elastic tissue present in the artery can stretch and return, allowing the arteries to adapt to changes in flow and blood pressure. The intima is also a very smoothe, slick layer so that blood can easily flow past it. Every layer of the artery has developed evolutionary traits that help your arterial system to maintain flexibility, strength and promote blood flow. Diseases and conditions like high cholesterol or high blood pressure, diabetes and others prevent the arteries from doing their function well by creating blockages or increasing the stress on one or more of the layers. For example, high blood pressure causes rips in the smooth lining of the Intima. Anybody who has experienced a pipe burst in a house knows that the damage can be extreme and can never fully be restored. Understanding the delicate functions of the arterial structure gives good incentive to treat them better. Conditions like high blood pressure, high cholesterol and lifestyle diseases such as diabetes create tears, holes, blockages, and can disrupt the functions of one or more layers. Getting patients to visualize the effect of bad eating habits on their anatomy helps to increase patient compliance. In modern society, the concept of highways goes hand in hand with the concept of traffic jams. Patients understand that the arterial highway is one that can never be jammed.  
Mr. Rohit Singh
over 5 years ago
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0
14

GP commissioners are not monitoring private contracts effectively, think tank says

A think tank has questioned whether the NHS in England can monitor the safety and effectiveness of thousands of contracts outsourced to the private sector. The Centre for Health and the Public Interest said that new information from clinical commissioning groups (CCGs) raised fresh doubt over the handling of some 15 000 contracts.  
feeds.bmj.com
about 4 years ago
Preview
0
11

“Human guinea pig” asks for animal studies

A trial participant whose request for animal data had been rejected turned to Peter Gøtzsche for help. It later emerged that the information he requested didn’t exist at the start of the human trial. He describes what happened and says the social contract between patients and corporate sponsors of drug trials is broken  
feeds.bmj.com
about 4 years ago