CHAPTER 5 Neurologic Disorders
Section One Inflammatory Disorders of the Nervous System
Multiple Sclerosis
Assessment
Signs and symptoms/physical findings
Damage to motor and sensory control centers
Urinary frequency, urgency, or retention; urinary and fecal incontinence; constipation.
Diagnostic Tests
MRI
Reveals presence of plaques and demyelinization in the CNS. This is the test of choice when MS is suspected, although it is not a definitive measure of MS. MRI technology is capable of identifying current sites of inflammation and demyelinization and showing changes associated with disease progression. T1-weighted MRI sequences may show hypointense lesions (black holes), a finding that correlates with axonal loss and indicates old lesions. T2-weighted MRI sequences can show old and new lesions and is used to document response to treatment. Gadolinium (Gd) enhancement shows areas of active demyelinization. MRI diffusion tensor imaging and MR spectroscopy often reveal involvement of otherwise normal-appearing white matter. Magnetization transfer imaging may show indirect evidence of axonal loss. MR spectroscopy can measure decline in a brain chemical called N-acetylaspartate (NAA) as a marker of axonal damage and appears to predict disease severity. Functional MRI (fMRI) can show new lesions. Fluid-attenuated inversion recovery (FLAIR) is also used for detecting cerebral lesions, and short tau inversion recovery (STIR) is useful in detecting demyelinization.
Collaborative Management
Pharmacotherapy
Steroidal antiinflammatory agents (e.g., methylprednisolone)
For an exacerbation and for optic neuritis to reduce symptoms by decreasing inflammation and associated edema of the myelin and thereby hastening onset of remission. Antacids, histamine H2-receptor blockers, insulin coverage, K+ supplements, diuretics, BP medications, and psychotropic agents may be given to combat side effects of steroids.
Antispasmodics and muscle relaxants (e.g., baclofen, tizanidine, dantrolene sodium, and methocarbamol)
Antidepressants (e.g., fluoxetine, nortriptyline, and sertraline)
For depression related to cerebral lesions. These agents also may reduce complaints of paresthesias.
Tranquilizers (e.g., diazepam)
For anxiety reducing and muscle relaxant effects, which may help with spasms and tremors.
Proton pump inhibitor (e.g., pantoprazole), histamine H2-receptor blockers (e.g., famotidine), and sucralfate
Analgesics (e.g., acetaminophen), neuropathic pain medications (e.g., anticonvulsants such as carbamazepine, topiramate, and lamotrigine; tricyclic antidepressants such as amitriptyline and imipramine), and medications used for facial trigeminal pain or limb burning (e.g., amantadine, topical capsaicin, misoprostol, mexiletine, perphenazine)
Dextromethorphan-quinidine combination
To reduce inappropriate emotional episodes (e.g., laughing and crying).
Speech therapy
Improves speech deficits using accessory respiratory muscles, tongue, and facial muscles.
Nursing Diagnoses and Interventions
Deficient knowledge
related to factors that aggravate and exacerbate MS symptoms
Nursing Interventions
♦ Assess patient’s facility with language; engage an interpreter or provide language-appropriate written materials if appropriate.
♦ Teach preventive measures, such as avoiding hot baths or showers and using acetaminophen or aspirin to reduce fever, if present. Inform patient and significant that heat, both external (hot weather, bath) and internal (fever), may be bothersome. It tends to aggravate weakness and other symptoms of MS. Also instruct patient in use of fans or air conditioning, chilled drinks, cool showers, and cool cloths to aid in reducing body temperature. High humidity with heat should be avoided.
♦ Caution patient to avoid exposure to persons known to have infections of any kind. Patients should receive immunizations and instructions in importance of and proper technique for handwashing. Infection often precedes exacerbations,
♦ Teach indicators of common infections and importance of seeking prompt medical treatment if they occur. Teach patient to monitor for increased frequency, urgency, or incontinence and to check urine for changes in odor or presence of cloudiness or blood. Instruct patient to check body temperature periodically for fever and indications that a UTI has reached the kidneys (e.g., costovertebral angle tenderness, chills, flank pain). The patient with MS is susceptible to UTI because of urinary retention. Because of the disease process, patients may not feel any pain with urination.
♦ Encourage patient to reduce factors that cause stress. Encourage use of stress reduction techniques such as progressive relaxation, self-coaching, and guided imagery. (See Health-seeking behaviors: Relaxation technique effective for stress reduction, p. 106.) There is a relationship between stress and fatigue and the exacerbations.
♦ Encourage patient to get sufficient rest, stop activity short of fatigue, and schedule activity and rest periods. Also teach how to conserve energy in ADL by sitting while getting dressed, rather than standing; sliding heavy objects along work surfaces, rather than lifting them; using a wheeled cart to transport items; having work surfaces at the proper height; and using assistive devices and delegating. Suggest that patient ask health care provider for medications, (e.g., amantadine, pemoline, modafinil) that combat fatigue.
♦ Identify priorities and eliminate nonessential activities. Encourage patient to plan each day, break projects into smaller tasks, distribute tasks throughout the day, rest before difficult tasks, and take planned recovery time after tasks. Deconditioning can be reduced with a planned exercise program that can be incorporated into a scheduled activity/rest plan. Depression can contribute to sense of fatigue, and antidepressants may help.
♦ Patients planning a pregnancy should consult and work with their health care providers before pregnancy. Provide information about birth control measures to female patients who desire counseling. There may be a decreased relapse rate during pregnancy but increased exacerbations post partum.
Nursing Interventions
♦ Provide verbal instructions and language-appropriate written handouts that describe names, purpose, dose, and schedule of the prescribed medications. Also discuss drug/drug, herb/drug, and food/drug interactions.
♦ Give patients taking glatiramer injections these additional instructions:
• Common side effects: self-limiting reaction of chest tightness, palpitation, flushing, panic, and anxiousness that may last 30 sec to 30 min after injection. Injection site reaction (redness, swelling, pain) is also common. Notify health care provider of injection site redness, ongoing chest pain, shortness of breath, or dizziness.
♦ Give patients taking interferon injections these additional instructions:
• Apply ice before injections and cortisone creams and rotate sites. This intervention helps reduce skin inflammation, redness, and irritation from the injection.
• Flulike symptoms following each injection (fever, chills, headache, muscle aches and pains, malaise) are common and usually can be managed with analgesics such as acetaminophen and antihistamines such as diphenhydramine.
• Other common side effects that may occur include fatigue, diarrhea, abdominal pain, nausea, vomiting, joint aches, back pain, and dizziness.
♦ Give patients taking steroids (e.g., methylprednisolone) these additional instructions:
• Common side effects: Na+ and fluid retention, hypertension, gastric ulcers, stomach upset, weakness, hypokalemia, mood changes, impaired wound healing, and masking of infections.
• Monitor weight and BP for evidence of fluid retention. Advise patient to report symptoms of K+ deficiency, such as anorexia, nausea, and muscle weakness, and to eat foods high in K+ (see Box 4-2 p. 174). Encourage a diet low in Na+ content (see Box 4-1, for high Na++ foods, p. 165). This is to minimize the potential for fluid retention.
• Take the medication with food, milk, or buffering agents. This helps prevent gastric irritation. Avoid aspirin, indomethacin, caffeine, or other gastrointestinal (GI) irritants while taking this medication; and taper off rather than abruptly stopping the drug when it is discontinued. This is to avoid adrenal crisis.
♦ Give patients taking antispasmotics/muscle relaxants (e.g., baclofen or dantrolene) these additional instructions:
• Common side effects: drowsiness, dizziness, fatigue, and nausea. In addition, dantrolene can cause diarrhea, muscle weakness, hepatitis, and photosensitivity.
• Take the medication with food, milk, or a buffering agent. This is to reduce gastric upset or nausea.
• Drowsiness is usually transient, so avoid activities that require alertness until the effect of the drug on the CNS is known. Avoid alcohol intake. This is because of the additive CNS depression effects.
• Baclofen can lower the seizure threshold and should be used cautiously and never stopped abruptly. Baclofen also may raise blood glucose levels, and individuals with diabetes mellitus (DM) may need an insulin dose adjustment. Watch carefully during transfer and ambulation. Some weak patients cannot tolerate the loss in spasticity that may be permitting them to bear weight.
• If taking dantrolene, monitor for and report fever, jaundice, dark urine, clay-colored stools, and itching. These signs and symptoms may signal hepatitis or severe diarrhea.
• If patient is on intrathecal baclofen, monitor for surgical complications such as CSF leak, wound dehiscence, catheter dislodgment, and meningitis (fevers, stiff neck, headache, altered mental status). Report pump catheter system failure (loss of effect) caused by catheter kink, breakage, or migration. Caution patient to avoid running out of medication. It is important to ensure continuous operation because abrupt discontinuation of medication can result in seizures.
♦ Give patients taking smooth muscle stimulants (e.g., bethanechol chloride) these additional instructions:
• Common side effects: hypotension, diarrhea, abdominal cramps, urinary urgency, and bronchoconstriction.
♦ Give patients taking smooth muscle relaxants (e.g., tolterodine) these additional instructions:
• Common side effects: dryness of the mouth, blurred vision, constipation, palpitations, tachycardia, decreased sweating, and urinary retention or overflow incontinence.
• Measures for remaining cool in hot or humid weather. Heat stroke is more likely to develop while taking the medication.
• Notify health care provider immediately if urinary retention or overflow incontinence occurs. In addition, if the patient can chew and swallow effectively, use sugarless gum, hard candy, or artificial saliva products. These may reduce mouth dryness.
♦ Give patients taking mitoxantrone these additional instructions:
• Patient will be evaluated for normal cardiac function before starting the drug and will need periodic cardiac monitoring. This is to ensure that there are no toxic cardiac effects.
• Report swelling of feet and lower legs, shortness of breath, mouth or lip sores, black tarry stools, jaundice, and stomach pains.
• Avoid people with infections or who have recently received live virus vaccinations. Report signs of infection to health care provider (e.g., fever, chills, cough, hoarseness, lower back or side pain, and painful or difficult urination). Medication can decrease WBC counts, and thus risk of infection is increased. Expect to have both WBC and liver function tests.
• Side effects that normally do not require medical attention include nausea, temporary hair loss, and menstrual changes. After taking medication, urine may be blue green for about 24 hr. The medication also may cause diarrhea, which should be reported if it continues.
Nursing Interventions
♦ Maintain a comfortable room temperature. Advise patient to keep environment cool in warm weather and avoid hot baths or showers. This is because heat tends to aggravate MS symptoms.
♦ Provide passive, assisted, or active ROM exercises q2h and periodic stretching exercises. Teach these exercises to patient and significant other, and encourage the performance of these exercises several times daily. This is to reduce muscle tightness and spasms. Tell patient to sleep in a prone position. This may help decrease flexor spasm of the hips and knees. Splints or cones for hands with elastic bands may help spasm. Ensure safety with transfers.
Patient-Family Teaching and Discharge Planning
♦ Remission/exacerbation aspects of the disease process and progression. Explain effects of demyelinization on sensory and motor function and factors that aggravate symptoms.
♦ Safety measures relative to decreased sensation, visual disturbances, and motor deficits, including fall prevention.
♦ Medications, including drug names, purpose, dosage, frequency, precautions, and potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.
♦ Exercises that promote muscle strength and mobility, measures for preventing contractures and skin breakdown, transfer techniques and proper body mechanics, and use of assistive devices and other measures to minimize neurologic deficits.
♦ Indications of constipation, urinary retention, or UTI; implementation of bowel and bladder training programs; and self-catheterization technique or care of indwelling urinary catheters.
♦ Indications of upper respiratory infection (URI); implementation of measures that help prevent regurgitation, aspiration, and respiratory infection.
♦ Dietary adjustments that may be appropriate for neurologic deficit (e.g., soft, semisolid foods for patients with chewing difficulties or a high-fiber diet for patients experiencing constipation).
♦ Importance of follow-up care, including visits to health care provider, PT, and OT, as well as speech, sexual, or psychologic counseling.
♦ Referrals to community resources, such as local and national Multiple Sclerosis Society chapters, public health nurse, visiting nurse association, community support groups, social workers, psychologists, vocational rehabilitation agencies, home health agencies, extended and skilled care facilities, and financial counseling. Additional general information can be obtained by accessing the following websites:
Guillain-Barré Syndrome
Assessment
Collaborative Management
vital capacity for weight. Head of bed (HOB) should be elevated, if BP permits, to aid respirations and prevent aspiration.Pharmacotherapy
Stool softeners (e.g., docusate), laxatives (e.g., bisacodyl), and suppositories
May be prescribed to prevent fecal impaction and minimize incontinence.
Proton pump inhibitor (e.g., pantoprazole), histamine H2-receptor blockers (e.g., famotidine), and sucralfate
Exercise and activity
Passive ROM exercise during acute phase with a goal of preventing contractures, dislocations, or subluxations. Turning and meticulous skin care to prevent skin breakdown are important interventions. After patient stabilizes, active ROM or active-assistive ROM is implemented, and PT and a rehabilitation program are initiated with a goal of early mobilization. OT and assistive devices or braces are employed so that patient can maintain mobility and independence with activities of daily living (ADL). Muscle strengthening exercises, conditioning exercises, and gait training are commonly prescribed.
Management of acute autonomic dysfunction
Short-acting antihypertensive agents for hypertension; intravascular volume expanders or vasopressors for hypotension; cardiac monitoring of dysrhythmias; gastric suction, nutrition, and parenteral fluids for adynamic ileus; and catheterization and medications for urinary retention. Phenoxybenzamine may be used to help with paroxysmal hypertension, headache, sweating, anxiety, and fever. Diabetes insipidus (DI) (see p. 404) and SIADH (see p. 409) have been reported; therefore urine output, state of hydration, and serum and urine electrolytes are monitored.
Nursing Diagnoses and Interventions
Ineffective breathing pattern
related to neuromuscular weakness or paralysis of the facial, throat, and respiratory muscles
Nursing Interventions
♦ Test for ascending loss of sensation by touching patient lightly with a pin or fingers at frequent intervals (hourly or more frequently initially). Assess from the level of the iliac crest upward toward the shoulders. Measure the highest level at which decreased sensation occurs. Decreased sensation often precedes motor weakness. If it ascends to the level of the T8 dermatome, anticipate that intercostal muscles (used with respirations) soon will be impaired. Also monitor for upper arm and shoulder weakness by checking patient for the presence of arm drift and inability to shrug the shoulders. This weakness precedes respiratory failure. Arm drift is detected in the following way: have patient hold both arms out in front of the body, level with the shoulders and with palms up; instruct patient to close eyes while holding this position. Weakness is present if one arm pronates or drifts down or out from its original position. Alert health care provider to significant findings.
♦ Assist with oral intake to detect changes or difficulties. Assess patient q8h and before oral intake for cough reflexes, gag reflexes, and difficulty swallowing. Deficiencies may indicate ascending paralysis.
♦ Observe for changes in mental status, LOC, and orientation. These may signal reduced oxygenation to the brain. Monitor patient’s respiratory rate (RR), rhythm, and depth. Watch for accessory muscle use, nasal flaring, dyspnea, shallow respirations, apnea, and loss of abdominal breathing. Auscultate for diminished breath sounds. Monitor patient for breathlessness while speaking. To assess for breathlessness, ask patient to take a deep breath and slowly count as high as possible on one breath. A reduced ability to count to a higher number before breathlessness occurs may signal grossly reduced ventilatory function.
♦ Check serial vital capacity results on pulmonary function tests. This is to monitor effectiveness of breathing. If vital capacity is less than 800-1000 mL or is rapidly trending downward or if patient exhibits signs of hypoxia such as tachycardia, increasing restlessness, mental dullness, cyanosis, decreased pulse oximetry readings, or difficulty handling secretions, report findings immediately to health care provider.
♦ Raise HOB and encourage coughing and deep breathing. This will promote optimal chest excursion and reduce aspiration risk.
♦ The patient may require tracheostomy, endotracheal intubation, or mechanical ventilation to support respiratory function. Prepare patient emotionally for such procedures or for the eventual transfer to ICU or transition care unit for closer monitoring.
Nursing Interventions
♦ For patients with muscle tenderness, consider use of massage, moist heat packs, cold application, or warm baths. This is very soothing for the muscles.
♦ For patients with hypersensitivity, assess amount of touch that can be tolerated and incorporate this information into patient’s plan of care.
♦ Reposition patient at frequent intervals. Some individuals find that a supine “frog-leg” position is particularly comfortable. Provide passive ROM and gentle stretching. This reduces muscle tension, joint stiffness, and fatigue.
♦ Opioids are often the most effective means of pain control, and a continuous morphine drip may be needed. Other medications that may be tried to relieve uncomfortable paresthesias include anticonvulsants and tricyclic antidepressants.
♦ For other nursing interventions, see Acute pain, p. 366, in “General Care of Patients with Neurologic Deficits.”
Nursing Interventions
♦ Monitor BP and note wide fluctuations; report significant findings to health care provider. Short-acting hypertensive agents may be required for persistent hypertension. Look for changes in heart rate (HR) and BP during activities such as coughing, suctioning, position changes, or straining at stool. Changes in BP that result in severe hypotension or hypertension may occur because of unopposed sympathetic outflow or loss of outflow to the peripheral nervous system that causes changes in vascular tone.
Nursing Interventions
♦ Auscultate abdominal sounds, and note presence, absence, or changes that may signal onset of ileus. Be alert to abdominal distention or tenderness, nausea and vomiting, and absence of stool output. Notify health care provider of significant findings.
♦ Patients with adynamic ileus generally require gastric decompression with a nasogastric (NG) tube. Because these patients are unable to take foods orally, parenteral nutrition may be required (see “Providing Nutritional Support,” p. 692).
♦ For general nursing interventions, see Imbalanced nutrition, p. 357, in “General Care of Patients with Neurologic Deficits.”
Nursing Interventions
♦ For patients with progressing neurologic deficit, transfer to a room close to nurses’ station to help alleviate the anxiety of being suddenly incapacitated and helpless.
♦ Perform assessments at frequent intervals, and let patient know you are there. Provide care in a calm and reassuring manner.
♦ Allow time for patient to ventilate concerns and provide realistic feedback regarding what patient may experience. Determine past effective coping behaviors and problem solve for ways these behaviors, or others, may prove useful in current situation.
Nursing Interventions
♦ Before the plasma exchange procedure, patient’s health care provider explains the reason for the procedure, its risks, and anticipated benefits or outcome. Determine patient’s level of understanding of health care provider’s explanation, and clarify or reinforce information accordingly. Assess patient’s facility with language; provide interpreter or language-appropriate written materials if indicated. Obtain signed permit.
♦ Notify health care provider if patient is taking angiotensin-converting enzyme (ACE) inhibitor medication. ACE inhibitor use is associated with flushing, hypotension, abdominal cramping, and other gastrointestinal (GI) signs and symptoms during plasmapheresis. These medications usually are held for 24 hr before the procedure to avoid problems.
♦ Determine patient’s experience with plasmapheresis, positive or negative effects, and nature of any fears or concerns. Document and communicate this information to other caregivers.
♦ Explain in words patient can understand that the goal of plasma exchange is to remove autoimmune factors from the blood to decrease or eliminate symptoms. These antibodies to patient’s peripheral and cranial nerve tissue are reduced by removal of the blood’s plasma portion, which contains the circulating antibodies. The procedure is similar to hemodialysis. Blood is removed from patient and separated into its components. The patient’s plasma is discarded; other blood components (e.g., RBCs, WBCs, platelets) are saved and returned to patient with donor plasma or replacement fluid. If started within 1-2 wk of GBS symptoms, the exchange process seems to decrease disease duration and severity. Multiple exchanges over a period of weeks can be expected.
♦ Patient is at risk for the following complications during this procedure: deficient fluid volume, hypotension, fluid overload, hypokalemia (from dilution with albumin replacement), hypocalcemia (from free calcium binding to the citrate used during the procedure), cardiac dysrhythmias (from electrolyte shifts), clotting disorders (from decreased clotting factors with plasma removal), anemia, phlebitis, infection, hypothermia, and air embolism. Answer any questions regarding these complications accordingly.
♦ This procedure requires good blood flow. The antecubital vein may be accessed, but the health care provider may need to insert a central IV line or a femoral catheter. If the antecubital site is used, place a sign alerting others to avoid using this site for routine laboratory needle sticks.
♦ Explain that patient can expect the procedure to take 2-4 hr, although it may take considerably longer, depending on condition of patient’s veins, blood flow, and hematocrit (Hct) level.
♦ Explain that patient can expect preprocedure and postprocedure blood work for clotting factors and electrolyte levels. Patient may be placed on cardiac monitoring. This is to assess for electrolyte imbalance, particularly if taking prednisone or digitalis. Weight and VS will be taken before and after the procedure, with frequent VS checks during the procedure. Calcium gluconate or KCl may be administered. This is to correct electrolyte imbalances.
♦ Encourage patient to report any unusual feelings or symptoms during plasma exchange—for example:
• Thirst, faintness, or dizziness. This can occur with hypotension or hypovolemia. Patients should take oral fluids during the procedure if possible.
♦ Inform patient that medications (e.g., plasma-bound drugs) may be held until after the procedure to prevent their removal from the blood.
♦ If the patient does not have a urinary catheter, remind the patient to void before and during the procedure. This is done to avoid any mild hypotension caused by a full bladder. I&O will be monitored closely. Decreased urine output may signal hypovolemia.
♦ Explain that patient’s temperature will be checked during the procedure and warm blankets will be provided. This is to prevent hypothermia.
♦ Explain that patient probably will feel fatigued 1-2 days after the procedure. This is caused by decreased plasma protein levels. Encourage extra rest and a high-protein diet during this time. Encourage consumption of milk products.
♦ Teach patient to monitor IV access site for signs of infection, such as warmth, redness, swelling, or drainage, and to report significant findings.
♦ Teach patient to monitor for signs of bruising or bleeding. The anticoagulant citrate dextrose is used in the extracorporeal machine circuitry to prevent clotting. This may cause excessive bleeding at the access site. Inform patient to observe for black, tarry stools. This finding usually signal spresence of blood. Tell patient that the presence of any of these signs should be reported.
Patient-Family Teaching and Discharge Planning
♦ Disease process, expected improvement, and importance of continuing in rehabilitation or PT program to promote as full a recovery as possible.
♦ Exercises that promote muscle strength and mobility, measures for preventing contractures and skin breakdown, transfer techniques and proper body mechanics, and use of assistive devices.
♦ Indications of constipation, urinary retention, or UTI; implementation of bowel and bladder training programs; and if appropriate, care of indwelling catheters or self-catheterization technique.
♦ Medications, including drug names, purpose, dosage, schedule, precautions, and potential side effects. Also discuss drug/drug, herb/drug, and food/drug interactions.
♦ Referrals to community resources such as public health nurse, visiting nurse association, community support groups, social workers, psychologic therapy, home health agencies, and extended and skilled care facilities. Additional general information can be obtained by accessing the following website:
Bacterial Meningitis
Overview/Pathophysiology
Meningitis generally is transmitted in one of four ways: (1) via airborne droplets or contact with oral secretions from infected individuals; (2) from direct contamination (e.g., from a penetrating skull wound; a skull fracture, often basilar, causing a tear in the dura; lumbar puncture (LP); ventricular shunt; or surgical procedure); (3) via the bloodstream (e.g., pneumonia, endocarditis); or (4) from direct contact with an infectious process that invades the meningeal membranes, as can occur with osteomyelitis, sinusitis, otitis media, mastoiditis, or brain abscess. In adults, pneumococcal meningitis, caused by Streptococcus pneumoniae, is the most common bacterial meningitis. Meningococcal meningitis, caused by Neisseria meningitidis, is next. Infection with Haemophilus influenzae type b has decreased significantly with the immunization of infants. Listeria monocytogenes infection is on the rise, especially in the immunocompromised or the extremely young or old. Outbreaks have been associated with consumption of contaminated dairy or undercooked fish, chicken, and meat. Any bacterium can cause meningitis, and some forms of meningitis, such as one caused by Staphylococcus aureus, can be difficult to treat because of their resistance to important antibiotics. Adhesions and fibrotic changes in the arachnoid layer and subspace may cause obstruction or reabsorption problems with CSF that result in hydrocephalus. Although the mortality rate is still high among untreated or delayed-treatment cases, prognosis for most patients with bacterial meningitis is generally good. Complete neurologic recovery is possible if the disorder is recognized early and antibiotic treatment is initiated promptly.
Assessment
Signs and symptoms/physical findings
Cardinal signs include headache, fever, stiff neck, change in mental status.
IICP and herniation
Decreased level of consciousness (LOC) (irritability, drowsiness, stupor, coma), nausea and vomiting, decreasing Glasgow Coma Scale (GCS) score (see p. 307), VS changes (increased BP, decreased heart rate [HR], widening pulse pressure), changes in respiratory pattern, decreased pupillary reaction to light, pupillary dilation or inequality, and severe headache.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
