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© Irene Mueller EdD, RHIA May 2, 2013

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1 © Irene Mueller EdD, RHIA May 2, 2013
Anatomy & Physiology of the Brain (Encephalon): Preparing for ICD-10-CM/PCS © Irene Mueller EdD, RHIA May 2, 2013

2 Have you completed the Pre-Test????
Objectives Review Brain Anatomy and Physiology for ICD-10-CM/PCS Coding Overlap of Circulatory and Nervous Systems Functions of Brain Components of Brain Cells of Brain Brain Nerves ICD 10 CM Terminology ICD 10 PCS Terminology Integrated into presentation Have you completed the Pre-Test????

3 Overlap of Circulatory and Nervous Systems in Brain
Connected through organ & bodily function control All body functions are regulated by brain through nervous system W/o messages from brain, circulatory system does not work Heart function & fluid circulation triggered by nervous system Messages sent from the brain control both blood and lymphatic parts of circulatory system Blood provides energy for brain Brain = 2% of mass, uses 20% of energy Avg weight of adult brain is about 3 pounds

4 Examples of Overlap in brain
Blood pressure and heart rate regulation Vagus nerve controls pumping of heart As heart pumps, blood moves through blood passageways around body to organs Baroreceptors pass information about blood pressure to brain so brain makes adjustments to heart rate Dependent on each other to ensure homeostasis Nervous system may have control, but circulatory system must relay information for adjustments Both systems need to function properly & work together to ensure proper body functions

5 Circulatory System Components of Brain
Precerebral Arteries AKA Extracranial Leading to cerebrum, but NOT in cerebrum Right vs Left for coding Basilar artery Carotid (Common, Internal) External does NOT feed brain) Vertebral Other Anterior spinal Auditory internal Cerebral Arteries AKA Intracranical Middle Cerebral Anterior /Posterior Communicating Anterior/Posterior Cerebral Cerebellar Other specified

6 Circle of Willis Basilar Internal carotid Vertebral artery

7 Functions of Brain Control Center of body
Maintains homeostasis (w/endocrine system)

8 Nervous System Components of Brain
Nervous system = 2 parts CNS = Brain and Spinal Cord (not part of this webinar) Cerebrum, cerebellum, brain stem PNS = Nerves and Ganglia Somatic – connect CNS with skeletal muscles and skin Autonomic – connect CNS with cardiac/smooth muscle and glands

9 Cerebrum (L, brain) Largest Part of brain
Cortex = Gray Matter on surface 6 layers of nerve cell bodies Millions of cells Cerebral White Matter Under cortex Myelinated axons of nerve cells Transmit in 3 directions Association = within same hemisphere Commissural = from one hemisphere to other Projection = from cerebrum to other parts of CNS

10 Functions of Cerebrum 3 general functions
Motor = Govern muscle movement Sensory = Interpret sensory input Vision = % of cortex Touch = % Hearing = 3 % Association = Emotional and intellectual processes

11 Cortex As brain grows, more gray matter
Cortex folds on itself, creating Gyri (AKA convolutions) Gk, gyro, circle Upfolds winding over surface Fissures – Deep downfolds Sulci –sulcus /sul·cus/ (sul´kus) pl. sul´ci   [L.] a groove, trench, or furrow shallow downfolds separating gyri

12 Hemispheres of Cerebrum
Right and Left halves of brain Divided by Longitudinal Fissure Connected by Corpus Callosum Large bundles of transverse nerve cell fibers “Rain Man” – born w/o Each hemisphere divided into 4 lobes Frontal, Parietal, Temporal, and Occipital Fifth lobe = Insula Oval region of cerebral cortex overlying extreme capsule, lateral to lenticular nucleus, buried in depth of the fissura lateralis cerebri (sylvian fissure) Separated from the adjacent frontal, parietal, and temporal opercula by circular sulcus of insula. Synonym(s): insular area, insular cortex, island of Reil

13 Corpus Callosum L, - callous, hard AKA colossal commissure of brain
A tract of nerve fibers passing from one side to other of spinal cord or brain Larger in women Can transfer data between R & L hemispheres faster than men Woman’s intuition

14 Lobes of Cerebrum

15 Frontal Lobe Functions
Responsible for higher cognitive functions, including: Problem solving Memory Language Judgment Spontaneity Motivation Impulse Control Social and Sexual Behavior

16 Temporal Lobe Functions
Role in emotions Responsible for Smelling Tasting Perception Memory Understanding music Aggressiveness Sexual behavior Language areas of brain

17 Language areas of Brain
Broca’s area French surgeon, 1861 Frontal lobe Motor neurons Control of Speech Wernicke’s area German pathologist, 1874 Temporal lobe Comprehension of Language, Speech sounds

18 Uncus L. – uncus – hook From Gk onkos
Hooklike anterior end of hippocampal gyrus on temporal lobe of brain

19 Parietal Lobe Functions
Role in sensations of touch, smell, and taste Processes sensory & spatial awareness Key part of eye-hand co-ordination & arm movement Wernicke’s area Matching written words to sound of spoken speech

20 Occipital Lobe Functions
Controls vision and recognition Visual perception Color recognition Receives visual input from retina Retina is part of brain Visual signals are interpreted in occipital lobes Each optic nerve has million fibers

21 Cerebellum Sited below back of cerebrum
Transverse fissure separates from cerebrum 2 hemispheres separated by vermis Both gray and white matter Connected to brain stem by cerebellar peduncles (paired fiber bundles)

22 Functions of Cerebellum
Motor area of brain Controls unconscious movements in skeletal muscles Coordination, Posture, Balance

23 Brain Stem Located below cerebrum & in front of cerebellum Structures
(from top to bottom) Thalamus Hypothalamus Midbrain Pons Medulla oblongata

24 Thalamus (Gk: Inner Room)
Oval-Shaped, Large, Located above midbrain Relays all sensory impulses (EXCEPT smell) to cerebral cortex “Gateway” Interprets and produces conscious Pain recognition

25 Corpus striatum Striped mass of white & grey matter located in front of thalamus in each cerebral hemisphere Consists of caudate nucleus and lenticular nucleus

26 Hypothalamus Controls many homeostasis-related body actions
Controls Body temperature Regulates Biorhythms (Wake/Sleep) ANS – heartbeat, food movement, urinary bladder Interprets viscera-based sensory impulses Regulates food intake (Hunger/Satiety) Regulates fluid intake (Thirst) Monitors/Works with endocrine system Responds to Mental states – Fear, etc.

27 Midbrain Connects Pons and Cerebellum Short, Constricted
Origination of 2 Cranial Nerves III – Oculomotor IV - Trochlear

28 Pons (L. Bridge) Located anterior to Cerebellum, above Medulla
Bridge between spinal cord & Brain Connects other parts of brain as well Origination for 4 cranial nerves V – Trigeminal VI – Abducens VII – Facial VIII – Vestibulocochlear

29 Medulla oblongata Origination for 4 cranial nerves
Lowest part of brain Form upper part of Spinal Cord Main Conduction Pathways 2 pyramids - ventral aspect Motor tracts from cortex to cord Nerve fibers cross to other side Extrapyramidal = functional, not anatomical, unit comprising nuclei & fibers (excluding pyramidal tract) involved in motor activities; control/coordinate especially postural, static, supporting, & locomotor mechanisms. 2 nuclei on dorsal aspect Receive sensory impulses from spinal cord (ascending) Relay to OPPOSITE side of medulla Origination for 4 cranial nerves IX – Glossopharyngeal X – Vagus XI – Accessory XII - Hypoglossal

30 Medulla oblongata, cont.
Reflex Centers Cardiac – Regulates Heartbeat Respiratory – Rate and Depth of Breath Vasoconstrictor – Regulates Diameter of Blood Vessels

31 Cerebellar peduncles  3 sets of paired bundles of hindbrain, connecting cerebellum to Midbrain (superior) Pons (middle) Medulla oblongata (inferior)

32 Tapetum of brain L. tapeta - a carpet
Layer of fibers of corpus callosum forming roof of part of lateral ventricle

33 Glands in the Brain Pineal (L., Pine cone) Pituitary
L. - pītuītārius pertaining to/secreting phlegm

34 Pineal Gland Endocrine gland Source of melatonin
Hormone derived from tryptophan Regulates circadian rhythm (sleep cycle) Located behind 3rd cerebral ventricle Midline of brain

35 Pituitary Gland Master gland
Central role in homeostasis, maintaining reproductive cycle, directing activity of other glands Anterior, intermediate, and posterior lobes function as 3 separate endocrine organs Distinct cell populations, secretory products, & regulatory mechanisms Anterior lobe secretes thyroid stimulating hormone, corticotropin, luteinizing hormone, follicle stimulating hormone, growth hormone, and prolactin. Regulated by hypothalamus via portal vascular system Posterior lobe releases oxytocin & vasopressin from axon terminals originating in cell bodies located in hypothalamus Intermediate lobe rudimentary in humans, but produces several hormones (which are just now being studied).

36 Limbic System of Brain Thalamus Hypothalamus Cingulate gyrus Amygdala
Hippocampus Basal Ganglia

37 Limbic System Functions
Regulates emotion and memory Directly connects lower & higher brain functions Influences Emotions Visceral responses to emotions Motivation and Mood Sensations of pain and pleasure

38 Limbic System Components
Cingulate gyrus , L. - Girdle (surrounding), Gk. - Circle Amygdala, Gk. – Almond (also used for tonsil) Hippocampus, Gk. – seahorse Basal Ganglia, Gk. - knot

39 Cingulate gyrus Part of cerebrum gray matter
Surrounds, directly connected to parts of inner Limbic System Serves as conduit for messages to and from inner Limbic System

40 Amygdala Makes associations across different modes of stimulus
Smell of lilacs = visual memory of my house in Great Falls Appears responsible for influence of emotional states on sensory inputs Same stimulus = Different perceptions Sound of USAF Jets not noise – memory of childhood Responsible for face recognition?

41 Hippocampus VERY important in transition of information from short to long term memory Search Engine of brain Learning and consciously remembering everyday facts and events Also part of Temporal Lobe Damage to that lobe can result in memory loss

42 Basal Ganglia AKA Substantia nigra, Subthalmic nucleus
Important in planning & coordinating motor movements and posture Basal Ganglia linked with Cerebral Cortex via complex neural connections Major effect of Basal Ganglia = Prevention of unwanted muscular activity Basal Ganglia Disorders result in exaggerated, uncontrolled movements

43 Ventricles (Ependyma)
Network of connected cavities filled with cerebrospinal fluid (CSF) 2 Lateral Ventricles Third Ventricle Cerebral Aqueduct AKA Aqueduct of Sylvius Fourth Ventricle

44 Functions of Ventricles
Choroid plexuses located in ventricles produce CSF, which fills ventricles & subarachnoid space Cycle of production and re-absorption (toxic wastes) Buoyancy, Protection, & Chemical stability Protection = CSF in meninges protects brain from striking cranium when head jolted Buoyancy = CSF and brain have similar density, so brain is suspended neutrally, allowing growth without sitting on bone CSF has protein, glucose, electrolytes, etc 500 ml per day, space for 130 ml in system

45 Meninges Protect brain and spinal cord 3 membranes
Dura mater = Outermost, tough, thick, fibrous Arachnoid = Middle, delicate, fibrous Pia Mater = Inner, transparent, tender Contains blood vessels Only layer that adheres to brain surface Leptomeninges – 2 innermost; CSF circulates between them Gk – Small, thin

46 CELLS OF THE BRAIN

47 Cells of Brain 100 billion neurons (nerve cells)
Sensory (afferent) – messages TO brain Motor (efferent) – messages FROM brain Trillions of Glia (Gk: Glue) (glial cells) AKA Neuroglia Connective tissue of brain 4 main types Astrocytes, ependymal cells, microglia, oligodentrocytes Common tumors of nervous system

48 3 classes of neurons Sensory neurons carry information from sense organs (such as eyes and ears) to brain Motor neurons control voluntary muscle activity (ex: speaking) carry messages from nerve cells in brain to muscles All other neurons are Interneurons

49 Neurons - 3 basic parts Cell body - includes nucleus, cytoplasm, and cell organelles Nucleus =DNA & information needed for growth, metabolism, and repair Cytoplasm = substance filling cell, including all chemicals/parts needed for cell to work properly Cell organelles = small structures (chromosomes, Golgi bodies, etc.) Dendrites Branch from cell body, act as point of contact for receiving impulses (chemical/electrical signals) from neighboring neurons Axon Sends impulses, extends from cell body to meet/deliver impulses to another nerve cell Range in length from fraction of inch to several feet Sciatic nerve axons extend from buttock to top of foot

50 Types of Glia cells Microglia = Brain’s immune system
Schwann cells/Oligodendrocytes form insulating sleeves around neurons to keep electric signals from diffusing (Myelin) Radial glia in developing brain After helpng neurons move around Then become astrocytes Ependymal cells (ependymocytes) Cells lining central canal of spinal cord (pyramidal shape) or brain ventricles (cuboidal shape) Produce/absorb/move (cilia) CSF

51 Myelin Insulating material wrapped around axons
Complex mixture of proteins and fats Nodes of Ranvier – gaps in myelin Electrical signal jumps from node to node Increases conduction speed of electrical signals along nerve fibers to muscle Made by Glial cells Oligodendrocytes in CNS Schwann cells in PNS Transmission electron micrograph of a myelinated axon, generated at the Electron Microscopy Facility at Trinity College, Hartford, CT

52 Astrocytes Have starlike rays Most abundant type of glial cells
Reach out in all directions Most abundant type of glial cells So, most abundant of all brain cells One astrocyte can wrap its rays around a million+ synapses Astrocytes fuse together Conduits for molecules moving from cell to cell

53 Brain Waves Cells in Cerebrum generate electrical potentials
Pass thru skull; Can be detected by electrodes EEG = recording/graph of brain waves Beta - consciously alert, or feeling agitated, tense, afraid Frequencies from 13 to 60 pulses/second in Hertz scale Alpha - state of physical and mental relaxation, but aware of surroundings Frequencies around 7 to 13 pulses/second Theta - state of somnolence w/reduced consciousness +/- 4 to 7 pulses/second Delta - unconsciousness, deep sleep or catalepsy 0.1 to 4 cycles/second

54 Nerves of the Brain

55 Cranial Nerves ICD-10-CM Index uses numerical order (first,
fourth, etc), but also provides names ICD-10-PCS uses NAMES only I II III V IV VI VI VIII AKA Auditory IX XII X Only First and Second Cranial Nerves originate in Cerebrum XI

56 Mnemonics for Cranial Nerves
On Old Olympus’ Towering Top A Famous Vocal German Viewed Some Hops On Old Olympic Towering Tops A Finn And German Viewed Some Hops OLd OPie OCcasionally TRies TRIGonometry And Feels VEry GLOomy VAGUe And HYPOactive Some Say Marry Money, But My Brother Says Big Business Makes Money Some say my mother bought my brother some bad beer, my, my S= Sensory, M = Motor, B = Both

57 Bonus Mnemonic for MS Some Lovers Try Positions That They Can't Handle!!! Scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate

58 Neurotransmitters Chemicals that run brain
60+ affect memory, learning, relationships Thoughts, Food, Drugs affect brain chemicals Stored in sacks near synapse at end of axon Electrical charges from cell body free chemicals, propel them across synapse Special receptors at end of dendrites form to accept certain neurotransmitters

59 Important Neurotransmitters
Serotonin Aids in smooth transmission of messages in brain/body Large role in regulating mood, appetite, memory & learning Lack of serotonin may result in low self-esteem, depression, aggression  Dopamine Helps information flow to higher brain levels Key role in regulating pain/pleasure Melatonin Related to wake/sleep cycles Epinephrine Moving body when needs instant action, - fear/danger Acetylcholine Enhances memory (chemical responsible for many dreams) Endorphin (neuropeptide) Body’s natural pain killer -lots of endorphin can create euphoric feelings Cortisol (neuropeptide) Released when under stress Can be dangerous at high levels – interrupts transmission of messages from neuron to neuron

60 Documentation Requirements for Coding
Laterality Specific Arteries Site Must use proximal branch for nerve that does not have separate body part value in ICD-10-PCS Ex: mandibular nerve is branch of trigeminal nerve, only the trigeminal nerve has a body part value When procedure performed on mandibular nerve, must assign trigeminal nerve for body part value

61 Artery/Nerve Families, etc. (ICD-10-PCS Body Key)
Alphabetical listing of body parts shows PCS Description to use with Table Rows when constructing a ICD-10-PCS code Anatomical Term PCS Description Caroticotympanic artery Internal Carotid Artery, R/L Carotid sinus nerve Glossopharyngeal nerve Leptomeninges Cerebral/Spinal meninges Mammillary body Hypothalamus Middle cerebral artery Intracranial artery

62 QUESTIONS? Homework Review Powerpoint before taking post-test
Go online to at least two of the Resource sites with Games and/or Quizzes and see what A&P about the brain you have learned/reinforced

63 Resources Amar AP, Weiss MH. Pituitary Gland Anatomy and Physiology. Abstract. Neurosurg Clin N Am Jan;14(1):11-23, v. Anatomy of the Brain. American Association of Neurological Surgeons. Anatomy of the Brain and Skull. Philips Medical Games. Brain Anatomy. Game. Brain Anatomy and Functions. Tutorial and Quiz. Getbodysmart.

64 Resources Cliff Notes. Anatomy & Physiology. Well-organized and includes quizzes. Cranial Nerves: Review Info. Quizzes. Cranial Nerves: Review Info Cranial Nerves Dirty Mnemonic Tutorial. Video. Crisan, E. Ventricles of the Brain. Jun 27, Medscape Reference.

65 Resources Kean, M. L. The Brain. Tutorial.
Division of Disability and Aging Services. Vermont. Brain 101: The neurotypical brain. Gray, H. Anatomy of the Human Body Human Brain Anatomy. Study and Quiz Modules. Interactive Tour of the Brain. National Brain Tumor Society. Intro to the Brain. ITS. San Diego State Univ. Includes Test. Kean, M. L. The Brain. Tutorial.

66 Resources Match a Brain. Game.
McGuire, N. ICD10 Session 11 Chapter 6. Codapedia. 32 Minute video. Neuron-Glia Interactions in Nerve Development and Disease. NIMH. Brain Basics. Pineal Gland. Encyclopedia Brittanica.

67 Resources Secret Life of the Brain. PBS. 3-D brain anatomy.
Tamarkin, D. A. Glia. University of Bristol. How the Brain Works. Video, 6+ min WebMD. Brain & Nervous System Health Center. WebMD. Medical References Related to Brain & Nervous System. Wernicke area. Encyclopedia Britannica. Videos, Animations.


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