Ruland PakasiPsychiatric Disorders? Psychiatric Disorders?
Psychiatric Disorders? Psychiatric Disorders?CoverageCoverageI.
Diagnostic ProcedureII. Examination of Cerebrospinal Fluid
(CSF)III. ab.!ests in Certain "eurologic Disorders10 Agustus 2015
FK UNDANA 2I.I.Neurologic Diagnostic ProceduresNeurologic
Diagnostic Procedures10 Agustus 20153Include Studies in:History
& Physical Examintaion guide the tests Laboratory StudiesBlood
!rine "S#"S# $cerebros%inal &luid'Imaging studiesFK UNDANAII.
EXAMINATION OFII. EXAMINATION OF CSF CSFPROCEDURE PROCEDUREOPERATOR
OPERATOR!"#ar P!$ct!re% "ost&y 'e&&($o'$ as Spinal
TapTo #e )er*or"ed #yEsta#&ished Ne!ro&ogistega&&y
&ice$ced )hysicia$ega&&y 'e&&+trai$ed MT10
Agustus 2015 FK UNDANA 4II. EXAMINATION OFII. EXAMINATION OF CSF
CSFINDICATION INDICATIONIndication!o e#aluate intracranial pressure
$ CSF abnormalities% categories&'. (enigeal infections).
(etastatic malignanc*+ 'mar* or )ndar*Dem*elinating diseases!o
administer intratr,ecal drugs or radiopa-ue agent for
m*elograp,*.10 Agustus 2015 FK UNDANA 5II. EXAMINATION OF II.
EXAMINATION OF CSFCSF, ,Re&ative Re&ative-- I
INTRAINDICATION NTRAINDICATIONI$*ectio$ at the )!$ct!re
site.&eedi$g diathesisI$creased i$tracra$ia& )ress!reChiary
I ty)e "a&*ro"atio$/10 Agustus 2015 FK UNDANA 6*brain tissue
protrudes into spinal canalII. Examination of CSFII. Examination of
CSFMost I")orta$t i$dicatio$0 Ide$ti1catio$ o* Me$i$gitis
es).#acteria&10 Agustus 2015 FK UNDANA 7Diseases detected #y
a#.E2a".o* CSF se$sitivity% s)eci1city.acteria&%
t!#erc!&o!s% a$d F!$ga& s)eci1city se$sitivity% "oderate
s)eci1city3ira& "e$i$gitis S!#arach$oid
he"orrhageM!&ti)&e sc&erosisCNS sy)hi&isI$*ectio!s
)o&y$e!ritisParas)i$a& a#scessII. Examination of CSFII.
Examination of CSFMost I")orta$t i$dicatio$0 Ide$ti1catio$ o*
Me$i$gitis es).#acteria&10 Agustus 2015 FK UNDANA 8Diseases
detected #y a#.E2a".o* CSFModerate se$sitivity%
s)eci1cityMe$i$gea& "a&ig$a$cyModerate se$sitivity%
"oderate s)eci1cityI$tracra$ia& he"orrhage3ira&
e$ce)ha&itisS!#d!ra& he"ato"eII. EXAMINATION OFII.
EXAMINATION OF CSF CSFRo!ti$e Ro!ti$eUse*!& !$derUse*!&
!$der certai$certai$ co$ditio$co$ditio$ Reco""e$ded CSF
a#.TestsO)e$i$g o* CSF Press!reTota& Ce&& Co!$t ,4.C 5
R.C-Di6ere$tia& Ce&& Co!$t ,stai$ed s"ear-7&!cose
,CSF8)&as"a ratio-Tota& )rotei$C!&t!res ,#acteria%
*!$gi% vir!ses% MT#c-7ra" stai$% acid+*ast stai$F!$ga& a$d
#acteria& a$tige$sE$9y"es ,D% C:+..-actatePo&y"erase chai$
reactio$% PCR ,T.% vir!ses-Cyto&ogyE&ectro)horesis
,)rotei$% i""!$o12atio$-etc10 Agustus 2015 FK UNDANA 9II.
EXAMINATION OFII. EXAMINATION OF CSF CSFNORMA NORMAA.NORMA
A.NORMA;.7ross E2a"i$atio$ ;.7ross E2a"i$atio$C&ear% viscocity
si"i&ar to 'ater.C&o!dy% *a$(&y )!r!&e$t% )ig"e$t
ti$gedT!r#idity8 c&o!d$ess #egi$s to a))ear0 4.C>
ce&&s8? or R.C > ce&&s8?7ross&y#&oody
CSF0 < A>>>8?3aryi$g degree o* c&o!d0
"icroorga$is"s% radiogra)hic co$trast "ateria&% as)irated
e)id!ra& *at% )rotei$ "g8dC&ot *or"atio$0Tra!"atic
ta)sCo")&ete s)i$a& #&oc(10 Agustus 2015 FK UNDANA
10II. EXAMINATION OFII. EXAMINATION OF CSF CSFA.NORMA;.7ross
E2a"i$atio$ ;.7ross E2a"i$atio$3isco!s CSF0Metastatic
"!ci$+)rod!ci$g ade$ocarci$o"asiC!id $!c&e!s )!&)os!s
,$eed&e i$D!ry to a$$!&!s 1#ros!s-Pi$(+red0I$dicates
)rese$ce o* #&ood% origi$ate *ro" s!#arach$oid he"orrhage%
i$tracere#ra& he"orrhage% cere#ra& i$*arct% or tra!"atic
ta)10 Agustus 2015 FK UNDANA 11II. EXAMINATION OFII. EXAMINATION OF
CSF CSFA.NORMA;.7ross E2a"i$atio$;.7ross
E2a"i$atio$Xa$thochro"iaXa$thochro"iaRe*er to )a&e )i$( to
ye&&o' co&or o* i$ the s!)er$ata$t o* ce$tri*!ged
CSFO'i$g to R.C &ysis a$d Eg# #rea(do'$Pi$(orange
colorOxyhemoglobin release2-4 hrs after subarachnoid hemorrhage,
peak 24-36 hrs, disappear the next4-8 days10 Agustus 2015 FK UNDANA
12II. EXAMINATION OFII. EXAMINATION OF CSF CSFA.NORMA;.7ross
E2a"i$atio$;.7ross
E2a"i$atio$Xa$thochro"iaXa$thochro"iaFe&&o' orange
colorDerived from bilirubin12 hrs after subarachnoid hemorrhage,
peak 2-4 hrs, may persist 2-4 wks10 Agustus 2015 FK UNDANA 13II.
EXAMINATION OFII. EXAMINATION OF CSF CSFA.NORMA;.7ross
E2a"i$atio$;.7ross E2a"i$atio$Xa$thochro"iaXa$thochro"iaA&so
visi#&e i$0Artefactual RBC lysis cause by detergent or delay
> 1 hr without refrigerationBilirubin in jaudiced patientsCSF
protein > 150mg/dL (traumatic tap, complete spinal block,
polyneuritis,meningitis, carotenoids (dietary hypercarotenemia),
meningeal metastatic melanoma (melanin), rifampicin therapy10
Agustus 2015 FK UNDANA 14II. EXAMINATION OFII. EXAMINATION OF CSF
CSFA.NORMADi6ere$tia& Diag $osis;.7ross E2a"i$atio$ ;.7ross
E2a"i$atio$Tra!"atic Tra!"atic vsvs Patho&ogic Patho&ogic
he"orrhage he"orrhageTra!"atic Tra!"aticG t!#es0 G t!#es0c&ear
c&ear CSF i$ the = CSF i$ the =$d $dR.C &ysis #egi$s as
ear&y as ;+= hrsR.C &ysis #egi$s as ear&y as ;+= hrs
a*ter s)i$a& ta) a*ter s)i$a& ta)ate2 agg&!ti$atio$
i""!$oassayate2 agg&!ti$atio$ i""!$oassay ,test *or 1#ri$
degradio$ ,derivative,test *or 1#ri$ degradio$ ,derivative
D+di"er-0D+di"er-0 $egative $egativePatho&ogic Patho&ogicG
t!#es0G t!#es0 re"ai$s 2a$thochro$icre"ai$s 2a$thochro$ic i$ = i$
=$d $d
i$ s!#arach$oid he"orrhage i$ s!#arach$oid he"orrhageMicrosco)ic
evide$ce0Microsco)ic evide$ce0 erythro)hagocyto sis% he"osideri$+
erythro)hagocyto sis% he"osideri$+&ade$ "acro)hages &ade$
"acro)hagesate2 agg&!ti$atio$ i""!$oassayate2 agg&!ti$atio$
i""!$oassay ,test *or 1#ri$ degradio$ ,derivative,test *or 1#ri$
degradio$ ,derivative D+di"er-0D+di"er-0 )ositive )ositive10
Agustus 2015 FK UNDANA 15II. EXAMINATION OFII. EXAMINATION OF CSF
CSFTota& Ce&& Co!$t Tota& Ce&& Co!$t4.C4.C
Di6ere$tia&Di6ere$tia& Co!$t Co!$t=.Microsco)ic E2a"i$atio
=.Microsco)ic E2a"i$atio$ $F!chs+Rose$tha& or
Ne!#a!erF!chs+Rose$tha& or Ne!#a!er co!$ti$g cha"#e co!$ti$g
cha"#er r4.C 4.CNor"a&% ad!&t0 >+B ce&&8?
Nor"a&% ad!&t0 >+B ce&&8?Neo$ates0 higher%
>+G> ce&&8? Neo$ates0 higher% >+G>
ce&&8?R.C sho!&d #e $egative. R.C sho!&d #e
$egative.Nor"a& DIFF Nor"a& DIFFy")hocytes0 A= H G@ I
y")hocytes0 A= H G@ IMo$ocytes0 GA H => I Mo$ocytes0 GA H =>
INe!tro)hi&s0 = H B I Ne!tro)hi&s0 = H B IEosi$o)hi&s0
rare Eosi$o)hi&s0 rareEistiocytes0 rare Eistiocytes0
rareE)e$dy"a& ce&&s0 rare E)e$dy"a& ce&&s0
rare10 Agustus 2015 FK UNDANA 16II. EXAMINATION OFII. EXAMINATION
OF CSF CSF;.Protei$s ;.Protei$sG.Che"ica& A$a&ysis
G.Che"ica& A$a&ysis;B+@B "g8d ;B+@B "g8d 0 0Tra!"atic
s)i$a& )!$ct!re Tra!"atic s)i$a& )!$ct!reI$creased
#&ood+CSFI$creased #&ood+CSF )er"ea#i&ity
)er"ea#i&ityArach$oiditis ,MTX thera)y- Arach$oiditis ,MTX
thera)y-Me$i$gitis ,#act% vira&% *!$ga&% t#c- Me$i$gitis
,#act% vira&% *!$ga&% t#c-Ee"orrhage
,s!#arach$oid%Ee"orrhage ,s!#arach$oid% i$tracere#ra&-
i$tracere#ra&-E$docri$e+"eta#o&ic disorders
E$docri$e+"eta#o&ic disordersMi&(+a&a(a&i sy$dro"e
'8 hy)erca&ce"ia Mi&(+a&a(a&i sy$dro"e '8
hy)erca&ce"iaEtha$o&% )he$othia9i$es% )he$ytoi$
Etha$o&% )he$othia9i$es% )he$ytoi$CSF circ!&atio$ de*ects
CSF circ!&atio$ de*ectsMecha$ica& o#str!ctio$ ,t!"or%
a#scess%Mecha$ica& o#str!ctio$ ,t!"or% a#scess% her$iated dis(-
her$iated dis(-oc!&ated CSF e6!sio$ oc!&ated CSF e6!sio$10
Agustus 2015 FK UNDANA 17II. EXAMINATION OFII. EXAMINATION OF CSF
CSF;.Protei$s ;.Protei$sG.Che"ica& A$a&ysisG.Che"ica&
A$a&ysis0 0I$creased Ig7 sy$thesis I$creased Ig7
sy$thesisNe!rosy)hi&is%
"!&ti)&esc&erosis%Ne!rosy)hi&is%
"!&ti)&esc&erosis% s!#ac!te sc&erosi$gs!#ac!te
sc&erosi$g )a$e$ce)ha&itis )a$e$ce)ha&itisI$creased Ig7
sy$thesis 5I$creased Ig7 sy$thesis 5 #&ood+CSF )er"ea#i&ity
#&ood+CSF )er"ea#i&ity7!i&&ai$+.are sy$dro"e
7!i&&ai$+.are sy$dro"eCo&&age$ vasc!&ar
diseaseCo&&age$ vasc!&ar disease ,&!)!s%
)eriarteritis- ,&!)!s% )eriarteritis-Chro$ic i$Ja""atory
Chro$ic i$Ja""atory%% de"ye&i$ati$g )o&yradic!&o)athy
de"ye&i$ati$g )o&yradic!&o)athy10 Agustus 2015 FK
UNDANA 18II. EXAMINATION OFII. EXAMINATION OF CSF CSF=.7&!cose
=.7&!coseG.Che"ica& A$a&ysisG.Che"ica&
A$a&ysisNor"a& Nor"a&B>+K> "g8d B>+K>
"g8d7&! CSF8P&as"a ratio0 >.G+>.L 7&!
CSF8P&as"a ratio0 >.G+>.LEy)og&ycorrhachia
Ey)og&ycorrhachia.acteria&% t!#erc!&o!s% 5
*!$ga&.acteria&% t!#erc!&o!s% 5 *!$ga& i$*ectio$s
,characteristic- i$*ectio$s ,characteristic-Me$i$goe$ce)ha&itis
,so"eMe$i$goe$ce)ha&itis ,so"e cases- cases-Other co$ditio$s
i$vo&vi$gOther co$ditio$s i$vo&vi$g "e$iges ,t!"or% s!#
arach$oid"e$iges ,t!"or% s!# arach$oid he"orrhage%
cysticercosis%he"orrhage% cysticercosis% sarcoidosis% etc-
sarcoidosis% etc-10 Agustus 2015 FK UNDANA 19II. EXAMINATION OFII.
EXAMINATION OF CSF CSF=.7&!cose =.7&!coseG.actate
G.actateG.Che"ica& A$a&ysisG.Che"ica&
A$a&ysisEy)erg&ycorrhachia Ey)erg&ycorrhachiaEas $o
c&i$ica& sig$i1ca$ce Eas $o c&i$ica&
sig$i1ca$ceL.> M =A "g8dN higher i$ L.> M =A "g8dN higher i$
$e'#or$s$e'#or$s0 0 3ira& "e$i$gitis ,O=B+GB 3ira&
"e$i$gitis ,O=B+GB "g8d- "g8d- vs vs .acteria&%"yco)&as"a%
.acteria&%"yco)&as"a% *!$ga& a$d t#c "e$i$gitis
*!$ga& a$d t#c "e$i$gitis , U8U))er &i"it0 K> U8 i$
#acteria& "e$i$gitis% i$ #acteria& "e$i$gitis% CNS
&e!(e"ia% &y")ho"a% CNS &e!(e"ia% &y")ho"a%
"etastatic carci$o"a% "etastatic carci$o"a% s!# arach$oid s!#
arach$oid he"orrhage.he"orrhage.No c&i$ica&&y
i$dicatio$No c&i$ica&&y i$dicatio$10 Agustus 2015 FK
UNDANA 22II. EXAMINATION OFII. EXAMINATION OF CSF CSFB.T!"or
"ar(ers B.T!"or "ar(ersCarcinoemb Carcinoembyonicyonic
antigenantigen (CEA) (CEA)HumanHuman chorionicchorionic gonadotropi
gonadotropin (HC)!n (HC)! " "#eto protein #eto
proteinG.Che"ica& A$a&ysisG.Che"ica&
A$a&ysisI$creased CEA i$ "etastatic I$creased CEA i$ "etastatic
#rai$ t!"ors ,@@I-% #rai$ t!"ors ,@@I-% "etastatic carci$o"e o* the
"etastatic carci$o"e o* the
&e)to"e$i$ges.&e)to"e$i$ges.Use*!& *or diag$osis 5
Use*!& *or diag$osis 5 "o$itori$g o* res)o$se "o$itori$g o*
res)o$se to thera)y i$ )atie$tsto thera)y i$ )atie$tsce&&
t!"ors.ce&& t!"ors.10 Agustus 2015 FK UNDANA 23II.
EXAMINATION OFII. EXAMINATION OF CSF CSF$acterial$acterial
meningitis meningitisSpirochetalSpirochetal meningitis
meningitis%iral%iral meningitis meningitisH&%
H&%#ungal#ungal meningitis meningitisTuberculousTuberculous
meningitis [email protected]#ia& @.Micro#ia&
E2a"i$atio$E2a"i$atio$7o to Micro#ia& 7o to Micro#ia&
De)art"e$tDe)art"e$t10 Agustus 2015 FK UNDANA 2410 Agustus 2015
25Co$ditio$ Press!re4#c8PPredo"i$a$t Ce&& Ty)e 7&!cose
Protei$Nor"a& ;>>M=>> "" E=O>MGB>M;>>
"g8d =>M@B "g8dAc!te #acteria&
"e$i$gitis;>>M;>%>>>PMN< ;>>
"g8dS!#ac!te "e$i$gitis ,T.% Cryptococcus i$*ectio$% sarcoidosis%
&e!(e"ia% carci$o"a-N or Q ;>>MR>> FK UNDANA10
Agustus 2015 26Co$ditio$ Press!re4#c8PPredo"i$a$t Ce&& Ty)e
7&!cose Protei$Ac!te sy)hi&itic "e$i$gitisN or Q
=BM=>>>NParetic $e!rosy)hi&isN or
Q;BM=>>>Ny"e disease o* CNSN or Q >MB>>N N or QFK
UNDANA10 Agustus 2015 27Co$ditio$ Press!re4#c8PPredo"i$a$t
Ce&& Ty)e 7&!cose Protei$.rai$ a#scess or t!"orN or Q
>M;>>>N3ira& i$*ectio$sN or
Q;>>M=>>>N N or QCere#ra& he"orrhage.&oody
R.Cs NCere#ra& thro"#osisN or Q >M;>>N N or QFK
UNDANA10 Agustus 2015 28Co$ditio$ Press!re4#c8PPredo"i$a$t
Ce&& Ty)e 7&!cose Protei$S)i$a& cord t!"orN
>MB>NN or 7!i&&ai$+.arrS sy$dro"eN >M;>>N
< ;>> "g8dead e$ce)ha&o)athy>MB>>NPse!dot!"or
cere#riNNFK UNDANAIII. ab.!ests in Se#eralIII. ab.!ests in Se#eral
"eurologic Disorders"eurologic Disorders10 Agustus 2015 FK UNDANA
29Blood BloodWBC: increased it! a s!i"t to t!e le"t#C$%
&C'$eacti(e %rotein) increases *ar+edl,Cerebrospinal
FluidCerebrospinal Fluid Appearance: opalescent to purulent-
slig!tl, ,ello- and *ig!t !a(e a coarse clot#WBC count. /5 to 0100
it! neutrop!ilic do*inance &0102)3 as t!e disease progresses
t!ere is a gradual increase in l,*p!octes and large *onoclear
cells# Cell counts abo(e 50#0004l raise t!e possibilit, t!at a
brain abscess !as ruptured into t!e subarac!noid space#5ra*'stained
s*ear: positi(e in 60'702 patients#Culture: positi(e in 65 to 702
patients# %rior antibiotic treat*ent decrease t!e "re8uenc, o"
positi(e cultures#III. ab.!ests in III. ab.!ests in Certain Certain
"eurologic Disorders"eurologic Disorders10 Agustus 2015 FK UNDANA
90Blood BloodWBC: increased it! a s!i"t to t!e le"t#C$%
&C'$eacti(e %rotein) increases *ar+edl,Cerebrospinal
FluidCerebrospinal Fluid %rotein 0 50 *g4dl##5lucose / :0 *g4dl
&0':0 *g4dl3 / 902 o" blood le(el).D; &especiall, .D;: and
.D;5) increase &t!is deri(ed "ro* granuloc,tes)#Bacterial
antigens: 502 to 1002 sensiti(it,# da*s of s*mptoms+ ele#ated CSF
protein /ndings 4ill be most prominent. (ost patients ,a#e fe4er
t,an '> leukoc*tes per milliliter+ but occasionall* a mild
ele#ation (ie+ '>21> cells7m) is seen. :reater t,an 1>
mononuclear cells7m of CSF casts some doubt on t,e diagnosis of
:6S.10 Agustus 2015 FK UNDANA 40STROKE, HEMORRHAGICLab
StudiesComplete blood count Coagulation profle Electrolytes Serum
glucose Blood type and screen10 Agustus 2015:1FK UNDANASTROKE,
ISCHEMICLab StudiesCBC, basic chemistry panel, coagulation studies,
and cardiac biomarkers should be obtained in most patients. CBC
serves as a baseline study and may reveal a cause for the stroke
(eg, polycythemia, thrombocytosis, thrombocytopenia, leukemia) or
provide evidence of concurrent illness (eg, anemia). Chemistry
panel serves as a baseline study and may reveal a stroke mimic (eg,
hypoglycemia, hyponatremia) or provide evidence of concurrent
illness (eg, diabetes, renal insufciency). Coagulation studies may
reveal a coagulopathy and are useful when thrombolytics or
anticoagulants are to be used. Cardiac biomarkers are important
because of the association of cerebral vascular disease and
coronary artery disease. Additionally, several studies have
indicated a link between elevations of cardiac enzyme levels and
poor outcome in ischemic stroke.Toxicology screening may be useful
in selected patients.10 Agustus 2015:2FK UNDANASUBARACHNOID
HEMORRHAGE SUBARACHNOID HEMORRHAGE (SAH)(SAH)Lab StudiesSerum
chemistry panel CBC count Prothrombin time (PT) and activated
partial thromboplastin time (aPTT) tests Blood typing/screening
testsCSF fndings suggesting subarachnoid hemorrhage include
numerous RBCs, xanthochromia, and increased pressure.About 6 h or
more after a subarachnoid hemorrhage, RBCs become crenated and
lyse, resulting in a xanthochromic CSF supernatant and visible
crenated RBCs (noted during microscopic CSF examination)10 Agustus
2015:9FK UNDANA6ellEs Pals*6ellEs Pals*a# St!dies In areas 4,ere
*me disease is endemic+ *me titers (Ig( and Ig:) s,ould be
obtained. 6lood glucose or ,emoglobin .'c ma* be obtained to
determine if t,e patient ,as undiagnosed diabetes. Serum titres(Ig(
and Ig.) forMycoplasma pneumoniae ma* be obtained.. stud* in
:erman*measured titres in patients 4it, 6ell pals* and found t,at
se#eral patients ,ad ele#ated titres toM pneumoniae+ and onl* ) of
t,ose 4,o tested positi#e ,ad respirator* s*mptoms.C Serum titers
for FSG ma* be obtained+ but t,is is usuall* not ,elpful o4ing to
t,e ubi-uitous nature of t,is #irus.*me disease is a
tick2transmitted infection caused b* 6orrelia burgdorferi. S*mptoms
include an er*t,ema migrans ras,+ 4,ic, ma* be follo4ed 4eeks to
mont,s later b* neurologic+ cardiac+ or 0oint abnormalities. 10
Agustus 2015 44 FK UNDANAa# St!diesH6C count C2reacti#e protein
(CRP) 6lood and cerebrospinal Auid culture to exclude bacterial
meningitis CSF & include mildl* or markedl* ele#ated pressure
presence of '> to = '>>> l*mp,oc*tes7I. :lucose mildl*
and protein le#els PCR of CSF can detect as fe4 as '> copies of
#iral nucleic acid. !,e abilit* to amplif* t,e D". from FSG2' and
FSG2)+ GJG+ C(G+ FFGK. and FFGK6+ and E6G Giral culture of t,roat
s4abs and stool sample Serolog*& Sa#e serum for paired
con#alescent sample comparison of serolog* at )2C 4eeks follo4ing
acute illness. CSF protein+ and mildl* decreased CSF glucose10
Agustus 2015 45 FK UNDANA10 Agustus 2015 46 FK UNDANA
