Diagnosis of Pick's Disease
Pick's Disease Diagnosis: Book Excerpts
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APHASIA, APRAXIA, AND AGNOSIA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it intermittent? Episodic aphasia, apraxia, or agnosia would suggest epilepsy, transient ischemic attacks, migraine, or hypertensive encephalopathy.
- Is it acute or gradual in onset? Acute onset of aphasia, apraxia, or agnosia would suggest a cerebral vascular accident, or if there is fever, the onset of a cerebral abscess. It may also mark the onset of acute encephalitis. The gradual onset of aphasia, apraxia, and agnosia would suggest a tumor or other type of space-occupying lesion.
- Is there associated headache or papilledema? Headaches with aphasia, apraxia, and agnosia might suggest migraine, but one should not forget a brain tumor. Obviously, papilledema is a sign of a space-occupying lesion.
- Is there significant dementia? The development of dementia along with the aphasia, apraxia, and agnosia suggest Alzheimer's disease, Pick's disease, herpes encephalitis, multiple sclerosis, or Korsakoff's psychosis.
DIAGNOSTIC WORKUP
All patients should have a CBC, sedimentation rate, chemistry panel, a VDRL test, and a CT scan of the brain. The CT scan may demonstrate an infarct, a space-occupying lesion, a degenerative disease, or multiple sclerosis. If this is negative, a neurologist should be consulted before ordering MRI or a spinal tap.
If the patient presents with intermittent aphasia, apraxia, or agnosia, an EEG should be done to rule out epilepsy, and a carotid scan should be done to rule out carotid stenosis or carotid plaques with ulceration. Four-vessel angiography may need to be considered, but a neurologist should be consulted before this is done.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Aphasia:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Stroke is the most common cause of aphasia
–Sudden onset suggests cerebral embolization from a cardiac (e.g., endocarditis, atrial fibrillation) or carotid artery source
–A stuttering onset suggests in situ arterial thrombosis
-
Less common etiologies include Alzheimer's dementia, postconcussion syndrome, Rasmussen's encephalitis, nonconvulsive status epilepticus, dissociative state, subdural hematoma, trauma, severe hypoglycemia, sedative-hypnotic drug intoxication, sensorineural hearing loss, herpes encephalitis, and tertiary syphilis
Types of aphasias
-
Receptive (Wernicke's) aphasia
–Inability to name objects, follow written or spoken commands, and repeat
–Verbal (semantic, neologistic) errors are abundant; however, speech is fluent
–Localized to the dominant posterior
superior temporal lobe
- Expressive (Broca's) aphasia
–Stuttering, nonfluent speech with literal (phonemic) errors; however, comprehension is preserved
–Repetition is poor, but naming is preserved
–Associated with hemiparesis
–Localized to the inferior lateral dominant
frontal lobe
-
Anomic aphasia
–Isolated inability to name a seen object
–Localized to the angular gyrus
-
Conduction aphasia
–Isolated inability to repeat
–Localized to the arcuate fasiculus (white matter band connecting Wernicke to Broca areas)
-
Transcortical sensory aphasia
–Similar to Wernicke's aphasia, except for preserved repetition
–Localized to the superior posterior temporal lobe
- Transcortical motor aphasia
–Similar to Broca's aphasia, but with preserved repetition, including urinary incontinence, echolalia (aimlessly repeating other's spoken words)
–Localized to medial dominant frontal lobe
Workup and Diagnosis
- History and physical examination
–History should include a complete past medical history, family history, psychiatric history, and medication history
–Exam should include a comprehensive neurologic exam, cardiovascular exam, and head and neck exam
–Fever and headache with aphasia suggests embolization from endocarditis or herpes simplex encephalitis
–Gradual onset with other signs of intellectual decline suggests dementia
-
The cornerstone of diagnosis is cerebral imaging (MRI has the highest sensitivity and specificity)
-
Initial laboratory tests should include CBC, electrolytes, BUN/creatinine, calcium, glucose, RPR, and vitamin B12 level
-
Consider toxicology screen
-
Echocardiography (transesophageal echocardiogram is best) and blood cultures may be indicated to diagnose endocarditis
-
CSF analysis and EEG to diagnose viral encephalitis versus status epilepticus
-
Psychometric testing necessary for dementia
-
Normal brain imaging with or without associated psychiatric signs may suggest status epilepticus, hypoglycemia, or a dissociative state
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Aphasia [Dysphasia]:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient doesn’t display signs of increased ICP or if his aphasia has developed gradually, perform a thorough neurologic examination, starting with the patient history. You’ll probably need to obtain this history from the patient’s family or companion because of the patient’s impairment. Ask if the patient has a history of headaches, hypertension, seizure disorders, or drug use. Also ask about the patient’s ability to communicate and to perform routine activities before aphasia began.
Check for obvious signs of neurologic deficit, such as ptosis or fluid leakage from the nose and ears. Take the patient’s vital signs and assess his LOC. Be aware, however, that assessing LOC is usually difficult because the patient’s verbal responses may be unreliable. Also, recognize that dysarthria (impaired articulation due to weakness or paralysis of the muscles necessary for speech) or speech apraxia (inability to voluntarily control the muscles of speech) may accompany aphasia; therefore, speak slowly and distinctly, and allow the patient ample time to respond. Assess the patient’s pupillary response, eye movements, and motor function, especially his mouth and tongue movement, swallowing ability, and spontaneous movements and gestures. To best assess motor function, first demonstrate the motions and then have the patient imitate them.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Aphasia [Dysphasia]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient doesn’t display signs of increased ICP, or if his aphasia has developed gradually, perform a thorough neurologic examination, starting with the patient history. You’ll probably need to obtain this history from the patient’s family or companion because of the patient’s impairment. Ask if the patient has a history of headaches, hypertension, seizure disorders, or drug use. Also ask about the patient’s ability to communicate and perform routine activities before he developed aphasia.
Check for obvious signs of neurologic deficit, such as ptosis or fluid leakage from the nose and ears. Take the patient’s vital signs and assess his LOC. Be aware, though, that the patient’s verbal responses may be unreliable, making LOC assessment difficult. Also, recognize that dysarthria (impaired articulation due to weakness or paralysis of the muscles necessary for speech) or speech apraxia (inability to voluntarily control the muscles of speech) may accompany aphasia, so speak slowly and distinctly, and allow the patient ample time to respond. Assess the patient’s pupillary response, eye movements, and motor function, especially his mouth and tongue movement, swallowing ability, and spontaneous movements and gestures. To best assess motor function, first demonstrate the motions and then have the patient imitate them.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Apraxia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you detect apraxia, ask about previous neurologic disease. If the patient fails to report such disease, begin a neurologic assessment. First, take the patient’s vital signs and assess his level of consciousness. Be alert for any evidence of aphasia or dysarthria. Ask the patient if he has recently experienced headaches or dizziness. Then test the patient’s motor function, observing for weakness and tremors. Next, use a small pin or another pointed object to test sensory function. Check deep tendon reflexes for quality and symmetry. Finally, test the patient for visual field deficits.
Be alert for signs and symptoms of increased intracranial pressure (ICP), such as headache and vomiting. If you detect these, elevate the head of the bed 30 degrees and monitor the patient closely for altered pupil size and reactivity, bradycardia, widened pulse pressure, and irregular respirations. Have emergency resuscitation equipment nearby, and be prepared to give mannitol I.V. to decrease cerebral edema.
If the patient is experiencing seizures, stay with him and have another nurse notify the physician immediately. Avoid restraining the patient. Help him to a supine position, loosen tight clothing, and place a pillow or other soft object beneath his head. If the patient’s teeth are clenched, don’t force anything into his mouth. If his mouth is open, protect the tongue by placing a soft object, such as a washcloth, between his teeth. Turn the patient’s head to provide an open airway.
After completing the examination and ensuring the patient’s safety, take a history. Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease. Then assess the apraxia further to help determine its type. (See Apraxia: Causes and associated findings, page 72.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Aphasia/Dysarthria:
Differential Overview
(Field Guide to Bedside Diagnosis)
Aphasia (Central)
❑ Broca
❑ Wernicke
❑ Conduction
❑ Anomic
❑ Global
❑ Motor aphasia
❑ Pure word deafness
❑ Alexia without agraphia
❑ Alexia with agraphia
Dysarthria (Peripheral)
❑ Bulbar
❑ Parkinson
❑ Multiple sclerosis
❑ Tongue infiltration
Diagnostic Approach
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Aphasia:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
A history will probably need to be obtained from the patient’s family or companion because of the patient’s impairment. Determine if the aphasia is new or when it began. Determine if the patient has a history of headaches, hypertension, seizure disorders, or drug use.
Physical examination
Perform a complete neurologic examination. Take the patient’s vital signs and assess his LOC. Be aware, though, that assessing LOC is commonly difficult because the patient’s verbal responses may be unreliable. Assess the patient’s pupillary response, eye movements, and motor function, especially his mouth and tongue movement, swallowing ability, and spontaneous movements and gestures. To best assess motor function, first demonstrate the motions and then have the patient imitate them. Don’t give liquids to drink until ordered due to the risk of aspiration.
Also, recognize that dysarthria (impaired articulation due to weakness or paralysis of the muscles necessary for speech) or speech apraxia (inability to voluntarily control the muscles of speech) may accompany aphasia; therefore, speak slowly and distinctly, and allow the patient ample time to respond. Check for obvious signs of neurologic deficit, such as ptosis or fluid leakage from the nose and ears.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Apraxia:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Obtain the patient’s history. Ask whether he has a previous history of neurologic disease. Does he have a history of headaches or dizziness?
Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease.
Physical examination
First, obtain the patient’s vital signs and assess his level of consciousness. Perform a neurologic assessment, staying alert for evidence of aphasia or dysarthria. Assess motor function, observing for weakness and tremors. Assist with testing sensory function, deep tendon reflexes, and visual field deficits.
Stay alert for signs and symptoms of increased intracranial pressure (ICP), such as headache and vomiting. If present, elevate the head of the bed 30 degrees and monitor the patient closely for altered pupil size and reactivity, bradycardia, widened pulse pressure, and irregular respirations. Have emergency resuscitation equipment nearby, and be prepared to give mannitol I.V. to decrease cerebral edema after inserting a urinary catheter to avoid bladder rupture.
If the patient is experiencing seizures, stay with him and have another nurse notify the physician immediately. Avoid restraining the patient. Assist him into a supine position, loosen tight clothing, and place a pillow or other soft object beneath his head. Don’t place anything into his mouth. Turn the patient’s head to the side to provide an open airway.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Aphasia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient doesn’t display signs of increased ICP, or if his aphasia has developed gradually, perform a thorough neurologic examination, starting with the patient’s history. You’ll probably need to obtain this history from the patient’s family or companion because of the patient’s impairment. Ask if the patient has a history of headaches, hypertension, seizure disorders, or drug use. Also ask about the patient’s ability to communicate and to perform routine activities before aphasia began.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Apraxia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If you detect apraxia, ask about previous neurologic disease. Ask the patient if he has recently experienced headaches or dizziness. Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease. Then assess the apraxia further to help determine its type.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Aphasia [Dysphasia]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient doesn't display signs of increased ICP or if his aphasia has developed gradually, perform a thorough neurologic examination, starting with his history. You may need to obtain this history from the patient's family or companion because of the patient's impairment. Ask if the patient has a history of headaches, hypertension, seizure disorders, or drug use. Ask about the patient's ability to communicate and to perform routine activities before aphasia began.
Check for obvious signs of neurologic deficit, such as ptosis, fluid leakage from the nose and ears, or motor impairment. Take the patient's vital signs and assess his LOC. Recognize that dysarthria (impaired articulation due to weakness or paralysis of the muscles necessary for speech) or speech apraxia (inability to voluntarily control the muscles of speech) may accompany aphasia; therefore, speak slowly and distinctly, and allow the patient ample time to respond. Assess the patient's pupillary response, eye movements, and motor function, especially his mouth and tongue movement, swallowing ability, and spontaneous movements and gestures. To best assess motor function, first demonstrate the motions and then have the patient imitate them.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
APHASIA, APRAXIA, AND AGNOSIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A thorough neurologic examination may disclose hemiparesis suggesting a
cerebrovascular accident or papilledema, suggesting a space-occupying
lesion. The history would be very important in ruling out alcohol or drug
intoxication, trauma, or autoimmune disorders. A CT scan would be useful in
acute cases, whereas an MRI would be best for cases with a gradual onset.
These studies would be most definitive for an infarct, space-occupying
lesion, or degenerative disorders. A VDRL test, ANA, CBC, and sedimentation
rate would be helpful to rule out systemic causes. A urine drug screen may
be necessary. For cases of intermittent symptoms, an EEG should be done to
rule out epilepsy, and a carotid scan should be done to rule out carotid
stenosis or plaque formation. A neurologist should be consulted if
four-vessel angiography is contemplated.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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