Myasthenia gravis



Three Types of Myasthenia gravis

  1. Ocular Myasthenia gravis

  • higher prevalence in males

  • muscle weakness confined to the eye

  1. Generalized Myasthenia gravis

  • affects the proximal musculature throughout the body with four different disease progressions

  1. a course with periodic remission

  2. a slow progression course

  3. a rapidly progressive course

  4. a fulminating course

  1. Bulbar myasthenia Myasthenia gravis

  • involves the muscles innervated by the cranial nerves IX, X, XI and XII

  • disease progression is typically rapid or fulminating


  • may present during pregnancy, post-partum or linked to the administration of some anesthetics

  • Fatigue after exercise

  • Hx of upper respiratory tract infections

  • muscles of eyes, face, mouth, throat and neck are affected first

Affected extraoccular muscles of the eye and levator muscles result in (Primarily):

  • diplopia

  • ptosis

  • ocular palsies

Affected muscles controlling facial expression, mastication, swallowing and speech result in (Secondary):

  • facial droop

  • no expressive ability

  • dysphagia

  • dysphasia

  • episodes of choking and aspiration

Muscles of neck, shoulder girdle, and hip girdle are less frequently affected resulting in:

  • pt experiences fatigue

  • periods of rest required

  • pt may have difficulty maintaining head position

  • muscles of diaphragm and chest wall become weakened

  • ventilation may be impaired

  • impairment of deep breathing and cough muscles predispose pt to atelectasis and congestion


Trauma Medicine


Police cars round in circles
The silence gathering
You never know what’s next down here
Close your eyes and shut your mouth

And I know I won’t last forever
Too young to die and too old
To believe in

The ambulance is singing
To streetcars in the rain
Like barracuda waiting
For the guns down in the hood 

But this ain’t no West Side Story
And the curtain’s comin’ down on me
Baby, baby, baby, baby
Too young to die and too old
To believe in

It’s all sound and all fury
It’s all reach and no touch
It’s all life’s cold bravado
All grown up and old so fast 

Too young to die and too old
I’m too young to die and too old
To believe in

Promises by Amanda Marshall

Multiple Sclerosis (MS)


Multiple sclerosis (MS) is a chronic condition that affects the central nervous system.

This system includes the brain and spinal cord. It contains the nerves that control everything your body does, such as thinking, feeling, seeing, smelling, tasting, and moving.

  • autoimmune based demylination in CNS
  • onset 20-40 yrs
  • incidence 2X higher in women than men


  • unclear
  • HLA genes affected on MHC portion of the chromosome
  • familial tendency
  • genetic susceptibility of immune response on HLA gene
  • viral trigger (EBV) – Ab attack myelin


  • demylination in white matter
  • inflammation
  • edema
  • destructive plaque formation resulting in conductive disorders
  • plaque (sclerotic patches) show lymphocytes and macrophage infiltration
  • death of oligodendrocytes which produce myelin
  • motor and sensory neurons are affected


  • depend on location and extent symptoms vary
  • may be a chronic pattern of remission and relapse
  • paresthesia – burning, tingling in extremities of regions where myelin sheathing is being destroyed
  • fatigue
  • decreased muscle strength, gait and coordination



proteins in CSF – indicative of:

  1. compromised blood brain barrier
  2. autoimmune damage is occurring
  3. inflammation is occurring in the CNS
  • MRI for plaques


  • steroid use for acute phases after relapse
  • disease modification eg interferon to manage antiviral, anti-inflammatory and autoimmune

Martin, Glenn and Porth, Carol, Mattson. 2009. Pathophysiology Concepts of Altered Health States. 8th ed. Lippincott Williams and Wilkins. Philadelphia

Cerebrovascular Accidents (Strokes)


Ischemic Stroke: sudden loss of function resulting from disruption of the blood supply to a part of the brain. Neurons die when they can no longer maintain aerobic respiration.

  • Event usually the result of long-standing cerebrovascular disease
  • early Tx results in fewer symptoms and less functional loss

5 different types

  1. large thrombosis – 20%
  2. small penetrating artery thrombosis – 25%
  3. cardiogenic embolic stroke – 20%
  4. cryptogenic 30%
  5. Other – 5%

Large artery thrombosis strokes: due to atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site af the atherosclerosis result in ischemia and infarction.

Small Penetrating artery thrombotic strokes: affect one or more vessels and are the most common type of ischemic stroke.

Aka lacunar strokes because of the cavity that is created once the infarcted brain tissue disintegrates.

Cardiogenic embolic strokes: are associated with cardiac dysrhythmias, usually atrial fibrillation. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Embolic strokes may be prevented by the use of anticoagulation therapy in patients with atrial fibrillation.

The 2 remaining categories of ischemic strokes are cryptogenic with no known cause and others causes such as cocaine, coagulopathies, migraine and spontaneous dissection of the carotid or vertebral arteries.


Martin, Glenn and Porth, Carol, Mattson. 2009. Pathophysiology Concepts of Altered Health States. 8th ed. Lippincott Williams and Wilkins. Philadelphia

BERG Balence Scale



Berg Balance Scale


The Berg Balance Scale is an a performance-based assessment tool that is used to evaluate standing balance during functional activities. The patient is scored on fourteen different tasks.


The Berg Balance Scale is a widely used assessment tool to identify balance impairment. Functional activities such as reaching, bending, transferring, and standing are evaluated on the test to evaluate balance. The test is often used for patients who exhibit a decline in function, self-report a loss of balance, or have unexplained falls. The test has also been used for patients with other diseases such as Parkinson’s disease, stroke, and multiple sclerosis.


Tests for balance should be conducted in a safe and controlled area where patients cannot be injured if they fall or become dizzy. The health care professional should evaluate the patient’s static and dynamic balance before leaving the patient unattended and provide close supervision during the test.


Balance is the ability to maintain the center of gravity over a base of support, usually in an upright position. With good balance, a patient has the ability to sit, stand, or walk safely, falling, or reaching for external items for support. Balance is complex and is a coordinated response of the neuromuscular and musculoskeletal systems. The Berg Balance Test was developed in the early 1990s as a means of measuring balance in the elderly. It has been shown to be a consistent and reliable test.

Patients are asked to complete fourteen tasks while an examiner rates the patient’s performance on each task. Elements of the test are representative of daily activities that require balance, such as sitting, standing, leaning over, and stepping. Some tasks are rated according to the quality of the performance of the task, while others are evaluated by the time required to complete the task.

The fourteen tasks evaluated in the Berg Balance Scale test include:

  • sitting unsupported
  • change of position: sitting to standing
  • change of position: standing to sitting
  • transfers
  • standing unsupported
  • standing with eyes closed
  • standing with feet together
  • tandem standing
  • standing on one leg
  • turning trunk (feet fixed)
  • retrieving objects from floor
  • turning 360 degrees
  • stool stepping
  • reaching forward while standing

Scores for each item can range from 0 (cannot perform) to 4 (normal performance). Overall scores can range from 0 (severely impaired balance) to 56 (excellent balance). Specifically, results are interpreted as:

  • 0-20: wheelchair bound
  • 21-40: walking with assistance
  • 41-56: independent

On average, patients with scores less than 40 are almost twelve times more likely to fall than those with scores higher than 40.


No special preparation is required prior to the administration of the Berg Balance Scale test.



Treatment of a patient who has been identified with a balance problem on the basis of the Berg Balance Scale may include strengthening, postural awareness exercises, various weight-shifting exercises, and increasing environmental stimuli in order to improve sensory awareness. The patient may be fearful of falling, and restoration of confidence may be required. Measures to take to decrease the likelihood of the patient falling include clear and safe pathways, adequate lighting, and guarding techniques by staff members.


A patient may be dizzy or exhibit other balance problems after completing the test, so the health care professional administering the test should make sure that the patient does not fall.


Results of the Berg Balance Scale are used to identify areas of impairment and the effects of the impairment on function. Results may also be useful in developing treatments that will restore the patient’s balance and mobility or identifying interventions to help the patient avoid falls. The test can also be used to evaluate and document progress over time.

Health care team roles

Nursing and other allied health professionals in hospitals, outpatient clinics, diagnostic centers, skilled nursing facilities, and assisted living facilities should be aware of their patients’ balance and other mobility characteristics. It is the responsibility of the health care provider to request the use of the Berg Balance Scale if appropriate to minimize the risk of falls. The test is usually administered by a physical therapist.



Close to home


When the evening falls and the daylight is fading,
from within me calls – could it be I am sleeping?
For a moment I stray, then it holds me completely.
close to home – I cannot say.
close to home feeling so far away.

As I walk there before me a shadow
from another world, where no other can follow.
carry me to my own, to where I can cross over…
close to home – I cannot say.
close to home feeling so far away.

Forever searching; never right, I am lost
in oceans of night. Forever
hoping I can find memories.
those memories I left behind.

Even though I leave will I go on believing
that this time is real – am I lost in this feeling?
like a child passing through, never knowing the reason.
I am home – I know the way.
I am home – feeling oh, so far away.

When the evening falls and the daylight is fading,
from within me calls – could it be I am sleeping?
For a moment I stray, then it holds me completely.

Evening falls – Enya

Timed Get Up and Go Assessment Tool (TUG)

  • Technique: Direct patient to do the following
    1. Rise from sitting position
    2. Walk 10 feet
    3. Turn around
    4. Return to chair and sit down
  • Interpretation
    1. Patient takes <20 seconds to complete test
      1. Adequate for independent transfers and mobility
    2. Patient requires >30 seconds to complete test
      1. Suggests higher dependence and risk of of falls