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Symptomatology
of Neurological
Disorders
III Term
Introductory Lecture
Series
Dr C Khati
Department of
Medicine
Thinking like a Neurologist
Is it Different?
Is it Difficult?
Always Ask
1. Where is the lesion?
2.
Always Ask
1. Where is the lesion?
2. What is the lesion?
Always Ask
1. Where is the lesion?
Neuro-Anatomical Diagnosis
2. What is the lesion?
Always Ask
1. Where is the lesion?
Neuro-Anatomical Diagnosis
2. What is the lesion?
Etiological Diagnosis
Complex Brain Processing
CC
HISTORY
EXAMINATION
Task and Goal
Task Goal
Chief Complaints Anatomical Localization
Task and Goal
Task Goal
Chief Complaints Anatomical Localization
History Taking Etiologies
Task and Goal
Task Goal
Chief Complaints Anatomical Localization
History Taking Etiologies
Neuro Examination Confirmation of
Anatomical Localization
Task and Goal
Task Goal
Chief Complaints Anatomical Localization
History Taking Etiologies
Neuro Examination Confirmation of
Anatomical Localization
Possible Diseases Review of Patient
Specific Features
Task and Goal
Task Goal
Chief Complaints Anatomical Localization
History Taking Etiologies
Neuro Examination Confirmation of
Anatomical Localization
Possible Diseases Review of Patient
Specific Features
Rank of order Differential Diagnosis
How to Start?
How to Start?
Knowledge Needs
How to Start?
Knowledge Needs
•Basic Neuroanatomy
•Basic Neurophysiology
•Etiological list
How to Start?
Knowledge Needs
•Basic Neuroanatomy
•Basic Neurophysiology
•Etiological list
…and a Symptom Based
Approach
Present Illness
• Symptoms
Clarify Symptoms
Onset, Duration and Progression
Onset
Some
Disability
Symptomatic Approach I
Disorder Analysis
Consciousness Level Content
Symptomatic Approach I
Disorder Analysis
Consciousness
Mental Functions Memory Intelligence
Personality Behavior
Dementia
Symptomatic Approach I
Disorder Analysis
Consciousness
Mental Functions
Higher Cortical Function Apraxia Agnosia
Aphasia Others
Symptomatic Approach I
Disorder Analysis
Consciousness
Mental Functions
Higher Cortical Function
Visual Visual Loss Diplopia
Symptomatic Approach II
Structure/ System Disorder
Language and Speech Dysarthria
Dysphasia
Symptomatic Approach II
Structure/ System Disorder
Language and Speech
Lower Cranial Nerves Deafness/ tinnitus
Vertigo
Balance/ staggering
Swallowing
Voice change
Symptomatic Approach III
System Disorder
Sensory •Pain
Headache
Facial Pain
Other Pain-
•Numbness and Tingling
•Others
Symptomatic Approach III
System Disorder
Sensory
Motor •Weakness/ Stiffness
•Wasting
•Fasciculations
•Movement Disorder
Sphincter
Symptomatic Approach III
System Disorder
Sensory
Motor
Sphincter •Incontinence
•Retention
Symptomatic Approach III
System Disorder
Sensory •Pain
Headache
Facial Pain
Other Pain-
•Numbness and Tingling
•Others
Motor
Sphincter
Symptomatic Approach III
System Disorder
Sensory
Motor •Weakness/ Stiffness
•Wasting
•Fasciculations
•Movement Disorder
Sphincter
Symptomatic Approach III
System Disorder
Sensory
Motor
Sphincter •Incontinence
•Retention
Symptomatic Approach IV
Temporal Profile Condition
Episodic
•Intermittent
•Remittent
•Seizure
•Syncope
•TIA
•Migraine
(Abnormal Movement)
Continuous
•Static
•Progressive
•Improving
Symptomatic Approach IV
Temporal Profile Condition
Episodic
•Intermittent
•Remittent
•Seizure
•Syncope
•TIA
•Migraine
(Abnormal Movement)
Continuous
•Static
•Progressive
•Improving
Symptomatic Approach IV
Temporal Profile Condition
Episodic
•Intermittent
•Remittent ?
•Seizure
•Syncope
•TIA
•Migraine
•(Abnormal Movement)
Continuous
•Static
•Progressive
•Improving
Symptomatic Approach IV
Temporal Profile Condition
Episodic
•Intermittent
•Remittent-
Demyelination
•Seizure
•Syncope
•TIA
•Migraine
(Abnormal Movement)
Continuous
•Static
•Progressive
•Improving
Present Illness
• Symptoms
Clarify Symptoms
Onset, Duration and Progression
Onset
Some
Disability
Data Collection – Skilled Task
Chief Complaints First Step- Get the Right
Data
Pattern Recognition Group of Symptoms
Mode of Onset
Data Collection – Skilled Task
Chief Complaints First Step- Get the
Right Data
Pattern Recognition Group of Symptoms
Mode of Onset
Data Collection – Skilled Task
Chief Complaints First Step- Get the
Right Data
Pattern Recognition Group of Symptoms
Mode of Onset
Common Mis- interpretations
Paralysis
Vs Numbness
Blurred vision
Vs Diplopia
Dizziness
Vs Weakness
Vs Fatigue
Blackout:
Loss of Conciousness
Vs Loss of Vision
Vs Confusion
Dysphasias
Vs Dysarthrias
Common Mis- interpretations
Paralysis
Vs Numbness
Blurred vision
Vs Diplopia
Dizziness
Vs Weakness
Vs Fatigue
Blackout:
Loss of Conciousness
Vs Loss of Vision
Vs Confusion
Dysphasias
Vs Dysarthrias
Common Mis- interpretations
Paralysis
Vs Numbness
Blurred vision
Vs Diplopia
Dizziness
Vs Weakness
Vs Fatigue
Blackout:
Loss of Conciousness
Vs Loss of Vision
Vs Confusion
Dysphasias
Vs Dysarthrias
Common Mis- interpretations
Paralysis
Vs Numbness
Blurred vision
Vs Diplopia
Dizziness
Vs Weakness
Vs Fatigue
Blackout:
Loss of Conciousness
Vs Loss of Vision
Vs Confusion
Dysphasias
Vs Dysarthrias
Common Mis- interpretations
Paralysis
Vs Numbness
Blurred vision
Vs Diplopia
Dizziness
Vs Weakness
Vs Fatigue
Blackout:
Loss of Conciousness
Vs Loss of Vision
Vs Confusion
Dysphasias
Vs Dysarthrias
Data from Chief Complaints and
Presenting Illness
• What and Where is the Lesion?
Data from Chief Complaints and
Presenting Illness
• What and Where is the Lesion?
• If Uninterpretable-
Recollect Data
Generalized Symptoms
• Headache
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
Generalized Symptoms
• Headache
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
Generalized Symptoms
• Headache
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
Generalized Symptoms
• Headache
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
Generalized Symptoms
• Headache
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
Generalized Symptoms
• Headache
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
Generalized Symptoms
• Headache
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
Focal Symptoms
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/ LMN)
• Sensory System(DC/ ST)
• Cerebellar Symptoms(Midline/ Lateral)
• Extra -pyramidal Symptoms
• Autonomic Symptoms (Sympathetic/ PS)
Focal Symptoms
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/ LMN)
• Sensory System(DC/ ST)
• Cerebellar Symptoms(Midline/ Lateral)
• Extra -pyramidal Symptoms
• Autonomic Symptoms (Sympathetic/ PS)
Focal Symptoms
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/ LMN)
• Sensory System(DC/ ST)
• Cerebellar Symptoms(Midline/ Lateral)
• Extra -pyramidal Symptoms
• Autonomic Symptoms (Sympathetic/ PS)
Focal Symptoms
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/ LMN)
• Sensory System(DC/ ST)
• Cerebellar Symptoms(Midline/ Lateral)
• Extra -pyramidal Symptoms
• Autonomic Symptoms (Sympathetic/ PS)
Focal Symptoms
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/ LMN)
• Sensory System(DC/ ST)
• Cerebellar Symptoms(Midline/ Lateral)
• Extra -pyramidal Symptoms
• Autonomic Symptoms (Sympathetic/ PS)
Focal Symptoms
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/ LMN)
• Sensory System(DC/ ST)
• Cerebellar Symptoms(Midline/ Lateral)
• Extra -pyramidal Symptoms
• Autonomic Symptoms (Sympathetic/ PS)
Focal Symptoms
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/ LMN)
• Sensory System(DC/ ST)
• Cerebellar Symptoms(Midline/ Lateral)
• Extra -pyramidal Symptoms
• Autonomic Symptoms (Sympathetic/ PS)
Focal Symptoms
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/ LMN)
• Sensory System(DC/ ST)
• Cerebellar Symptoms(Midline/ Lateral)
• Extra -pyramidal Symptoms
• Autonomic Symptoms (Sympathetic/ PS)
Combinations
• Headache/ Facial Pain
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/
LMN)
• Sensory System(DC/ ST)
• Cerebellar symptoms
(Midline/ Lateral)
• Extra -pyramidal
Symptoms
• Autonomic Symptoms
(Sympathetic/ PS)
Combinations
• Headache/ Facial Pain
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/
LMN)
• Sensory System(DC/ ST)
• Cerebellar symptoms
(Midline/ Lateral)
• Extra -pyramidal
Symptoms
• Autonomic Symptoms
(Sympathetic/ PS)
Combinations
• Headache/ Facial Pain
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/
LMN)
• Sensory System(DC/ ST)
• Cerebellar symptoms
(Midline/ Lateral)
• Extra -pyramidal
Symptoms
• Autonomic Symptoms
(Sympathetic/ PS)
Combinations
• Headache/ Facial Pain
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/
LMN)
• Sensory System(DC/ ST)
• Cerebellar symptoms
(Midline/ Lateral)
• Extra -pyramidal
Symptoms
• Autonomic Symptoms
(Sympathetic/ PS)
Combinations
• Headache/ Facial Pain
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/
LMN)
• Sensory System(DC/ ST)
• Cerebellar symptoms
(Midline/ Lateral)
• Extra -pyramidal
Symptoms
• Autonomic Symptoms
(Sympathetic/ PS)
Combinations
• Headache/ Facial Pain
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/
LMN)
• Sensory System(DC/ ST)
• Cerebellar symptoms
(Midline/ Lateral)
• Extra -pyramidal
Symptoms
• Autonomic Symptoms
(Sympathetic/ PS)
Combinations
• Headache/ Facial Pain
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/
LMN)
• Sensory System(DC/ ST)
• Cerebellar symptoms
(Midline/ Lateral)
• Extra -pyramidal
Symptoms
• Autonomic Symptoms
(Sympathetic/ PS)
Combinations
• Headache/ Facial Pain
• Altered Consciousness
• Behavioral Changes
• Memory Disturbances
• Intellectual Decline
• Generalized Weakness
• Generalized Seizure
• Focal Seizure
• Speech and Phonation
• Cranial Nerves Deficits
• Motor System(UMN/
LMN)
• Sensory System(DC/ ST)
• Cerebellar symptoms
(Midline/ Lateral)
• Extra -pyramidal
Symptoms
• Autonomic Symptoms
(Sympathetic/ PS)
Common Patterns
• Coma
• Dementias
• III, IV & VI
• V & VII Cranial Nerves
• Lower Cranial Nerves
• Hemiplegia
• Paraplegia
• Extrapyramidal
Disorders
• Cerebellar
• Polyneuropathy
• Peripheral Neuropathy
• Neuromuscular
Disorders
• Muscle Diseases
Common Patterns
• Coma
• Dementias
• III, IV & VI
• V & VII Cranial Nerves
• Lower Cranial Nerves
• Hemiplegia
• Paraplegia
• Extrapyramidal
Disorders
• Cerebellar
• Polyneuropathy
• Peripheral Neuropathy
• Neuromuscular
Disorders
• Muscle Diseases
Common Patterns
• Coma
• Dementias
• III, IV & VI
• V & VII Cranial Nerves
• Lower Cranial Nerves
• Hemiplegia
• Paraplegia
• Extrapyramidal
Disorders
• Cerebellar
• Polyneuropathy
• Peripheral Neuropathy
• Neuromuscular
Disorders
• Muscle Diseases
Common Patterns
• Coma
• Dementias
• III, IV & VI
• V & VII Cranial Nerves
• Lower Cranial Nerves
• Hemiplegia
• Paraplegia
• Extrapyramidal
Disorders
• Cerebellar
• Polyneuropathy
• Peripheral Neuropathy
• Neuromuscular
Disorders
• Muscle Diseases
Common Patterns
• Coma
• Dementias
• III, IV & VI
• V & VII Cranial Nerves
• Lower Cranial Nerves
• Hemiplegia
• Paraplegia
• Extrapyramidal
Disorders
• Cerebellar
• Polyneuropathy
• Peripheral Neuropathy
• Neuromuscular
Disorders
• Muscle Diseases
Common Patterns
• Coma
• Dementias
• III, IV & VI
• V & VII Cranial Nerves
• Lower Cranial Nerves
• Hemiplegia
• Paraplegia
• Extrapyramidal
Disorders
• Cerebellar
• Polyneuropathy
• Peripheral Neuropathy
• Neuromuscular
Disorders
• Muscle Diseases
Common Patterns
• Coma
• Dementias
• III, IV & VI
• V & VII Cranial Nerves
• Lower Cranial Nerves
• Hemiplegia
• Paraplegia
• Extrapyramidal
Disorders
• Cerebellar
• Polyneuropathy
• Peripheral Neuropathy
• Neuromuscular
Disorders
• Muscle Diseases
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Analysis
• Pattern Recognition
• Context Recognition
Common Etiologies
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/ Demyelinating
• Idiopathic
• Psychogenic
Analysis
• Pattern Recognition
• Context Recognition
20 year Female; Headache X 2 days
• Started at the back of the head spread all over
• Sudden onset, crescendo pattern
• Aggravated by coughing/ straining
• No relief with NSAID
• Associated with vomiting
• No fever
20 year Female; Headache X 2 days
• Had a generalized seizure in the bathroom,
following which she did not regain
consciousness for several hours- to days
20 year male; Headache X 2 days
• Started on left side around the eyes, spread all
over, Throbbing character
• More in the evening
• Aggravated by coughing/ straining
• Partial relief with Aspirin
• Associated with vomiting, noise intolerance,
photophobia
• No fever
• Exam around corner, studying late, missed a meal
• Similar headache in the past
40 Year old Executive; Headache X 3 weeks
• Insidious onset, frontal region
• More in the morning, Better by evening,
• Partial relief with NSAIDS
• Has been vomiting for past week effortlessly,
• Weakness and stiffness of right upper limb
noticeable for past few days
• Wife reports a mild change in personality
List of Problems
Integrate History and Physical Exam
First
• Anatomical localization
of lesion
• Focal, multifocal or diffuse
• Nucleus, tract or system
disorder
• CNS/ PNS or both?
Second
Cause of Lesion
• Congenital/ inherited
• Trauma
• Tumor
• Infection
• Vascular
• Metabolic/ Toxic/Nutritional
• Degenerative/
Demyelinating
• Idiopathic
• Psychogenic
Case1 : 25 year old soldier on leave
Brought by relatives
• Weakness of all 4 limbs X 5 days
• Difficulty in breathing X 1 day
• Noticed weakness of left LL on waking up.A few hours later
similar complaint started in the right LL. A day later same
problem developed in the upper limbs too. There has been
rapid worsening. For the past 2 days he is unable to get up
from the bed. Since yesterday he has developed difficulty in
breathing. No cough……
• No sensory complaints. No suggestion of cranial nerve
involvement/ seizures/ bowel & bladder disturbances
• Diarrheal illness 2 weeks ago
25 year old soldier on leave
• Clinically- T 99 degree F
• Pulse 120/ min
• BP 160/100
• Tachypnea- shallow respiration
• Chest expansion 1 cm
• Wasting
• Decreased tone
• Grade 0 to 2 power
• Areflexia- all 4 limbs
25 year old soldier
• Where &
• What is the lesion ?
25 year old soldier
• Acute, Asymmetric, Areflexic, Quadriparesis
(Polyradiculopathy)
• Post infective
Gullian Barre Syndrome
25 year old soldier
• What are the urgencies?
25 year old soldier
• Respiratory Neuromuscular Failure
• Dysautonomia
Case 2: 30 year old lady
• Burning pain like a band on the right side of
the chest X 2 days
• Few blisters over the same area- this morning
• What?
• Where?
Case 3: 45 year old Hypertensive
• Weakness left side of body X 6 hours
• Sudden onset, while sitting at the table, progressed
rapidly over 1 hour, no improvement
• Where is the lesion?
• What is the lesion?
Case 1: Female 35 Ys SLE on
Prednisolone 5 mg/ day
• Acute R Hemiparesis X 1 day
• CT Brain Acute R MCA Infarct
• EKG at admission: AF with Rapid Vent Rate,
CHF
• Summary of Problem list:
– Acute Stroke
– AF with CHF
– SLE on Prednisolone
Organise your thoughts
Acute Stroke
AF with CHF
SLE on
Prednisolone
Lateral Thinking
Ac Stroke from AF/
Other problems in
SLE
Ac Stroke
from AF/AF
From Carditis/
Carditis from
SLE
Ac Stroke from
other causes/
SLE ass. Stroke
(Vasculitis, APL)/
Treatment ass.
stroke- infection AF
due to stroke
Exercise your thought processes
• Bedside discussions
• Study case records
Equipment Needed
• Pen Light/ Scope
• Knee Hammer
• 128 &n 512 Tuning Forks
• Cotton Swabs
• Pins
• Calliper/ Divider
• Tubes for hot and cold water
• Stoppered containers for odour/ taste
•

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Approach to neurological disorders

  • 1. Symptomatology of Neurological Disorders III Term Introductory Lecture Series Dr C Khati Department of Medicine
  • 2. Thinking like a Neurologist Is it Different? Is it Difficult?
  • 3. Always Ask 1. Where is the lesion? 2.
  • 4. Always Ask 1. Where is the lesion? 2. What is the lesion?
  • 5. Always Ask 1. Where is the lesion? Neuro-Anatomical Diagnosis 2. What is the lesion?
  • 6. Always Ask 1. Where is the lesion? Neuro-Anatomical Diagnosis 2. What is the lesion? Etiological Diagnosis
  • 8. Task and Goal Task Goal Chief Complaints Anatomical Localization
  • 9. Task and Goal Task Goal Chief Complaints Anatomical Localization History Taking Etiologies
  • 10. Task and Goal Task Goal Chief Complaints Anatomical Localization History Taking Etiologies Neuro Examination Confirmation of Anatomical Localization
  • 11. Task and Goal Task Goal Chief Complaints Anatomical Localization History Taking Etiologies Neuro Examination Confirmation of Anatomical Localization Possible Diseases Review of Patient Specific Features
  • 12. Task and Goal Task Goal Chief Complaints Anatomical Localization History Taking Etiologies Neuro Examination Confirmation of Anatomical Localization Possible Diseases Review of Patient Specific Features Rank of order Differential Diagnosis
  • 15. How to Start? Knowledge Needs •Basic Neuroanatomy •Basic Neurophysiology •Etiological list
  • 16. How to Start? Knowledge Needs •Basic Neuroanatomy •Basic Neurophysiology •Etiological list …and a Symptom Based Approach
  • 17. Present Illness • Symptoms Clarify Symptoms Onset, Duration and Progression Onset Some Disability
  • 18. Symptomatic Approach I Disorder Analysis Consciousness Level Content
  • 19. Symptomatic Approach I Disorder Analysis Consciousness Mental Functions Memory Intelligence Personality Behavior Dementia
  • 20. Symptomatic Approach I Disorder Analysis Consciousness Mental Functions Higher Cortical Function Apraxia Agnosia Aphasia Others
  • 21. Symptomatic Approach I Disorder Analysis Consciousness Mental Functions Higher Cortical Function Visual Visual Loss Diplopia
  • 22. Symptomatic Approach II Structure/ System Disorder Language and Speech Dysarthria Dysphasia
  • 23. Symptomatic Approach II Structure/ System Disorder Language and Speech Lower Cranial Nerves Deafness/ tinnitus Vertigo Balance/ staggering Swallowing Voice change
  • 24. Symptomatic Approach III System Disorder Sensory •Pain Headache Facial Pain Other Pain- •Numbness and Tingling •Others
  • 25. Symptomatic Approach III System Disorder Sensory Motor •Weakness/ Stiffness •Wasting •Fasciculations •Movement Disorder Sphincter
  • 26. Symptomatic Approach III System Disorder Sensory Motor Sphincter •Incontinence •Retention
  • 27. Symptomatic Approach III System Disorder Sensory •Pain Headache Facial Pain Other Pain- •Numbness and Tingling •Others Motor Sphincter
  • 28. Symptomatic Approach III System Disorder Sensory Motor •Weakness/ Stiffness •Wasting •Fasciculations •Movement Disorder Sphincter
  • 29. Symptomatic Approach III System Disorder Sensory Motor Sphincter •Incontinence •Retention
  • 30. Symptomatic Approach IV Temporal Profile Condition Episodic •Intermittent •Remittent •Seizure •Syncope •TIA •Migraine (Abnormal Movement) Continuous •Static •Progressive •Improving
  • 31. Symptomatic Approach IV Temporal Profile Condition Episodic •Intermittent •Remittent •Seizure •Syncope •TIA •Migraine (Abnormal Movement) Continuous •Static •Progressive •Improving
  • 32. Symptomatic Approach IV Temporal Profile Condition Episodic •Intermittent •Remittent ? •Seizure •Syncope •TIA •Migraine •(Abnormal Movement) Continuous •Static •Progressive •Improving
  • 33. Symptomatic Approach IV Temporal Profile Condition Episodic •Intermittent •Remittent- Demyelination •Seizure •Syncope •TIA •Migraine (Abnormal Movement) Continuous •Static •Progressive •Improving
  • 34. Present Illness • Symptoms Clarify Symptoms Onset, Duration and Progression Onset Some Disability
  • 35. Data Collection – Skilled Task Chief Complaints First Step- Get the Right Data Pattern Recognition Group of Symptoms Mode of Onset
  • 36. Data Collection – Skilled Task Chief Complaints First Step- Get the Right Data Pattern Recognition Group of Symptoms Mode of Onset
  • 37. Data Collection – Skilled Task Chief Complaints First Step- Get the Right Data Pattern Recognition Group of Symptoms Mode of Onset
  • 38. Common Mis- interpretations Paralysis Vs Numbness Blurred vision Vs Diplopia Dizziness Vs Weakness Vs Fatigue Blackout: Loss of Conciousness Vs Loss of Vision Vs Confusion Dysphasias Vs Dysarthrias
  • 39. Common Mis- interpretations Paralysis Vs Numbness Blurred vision Vs Diplopia Dizziness Vs Weakness Vs Fatigue Blackout: Loss of Conciousness Vs Loss of Vision Vs Confusion Dysphasias Vs Dysarthrias
  • 40. Common Mis- interpretations Paralysis Vs Numbness Blurred vision Vs Diplopia Dizziness Vs Weakness Vs Fatigue Blackout: Loss of Conciousness Vs Loss of Vision Vs Confusion Dysphasias Vs Dysarthrias
  • 41. Common Mis- interpretations Paralysis Vs Numbness Blurred vision Vs Diplopia Dizziness Vs Weakness Vs Fatigue Blackout: Loss of Conciousness Vs Loss of Vision Vs Confusion Dysphasias Vs Dysarthrias
  • 42. Common Mis- interpretations Paralysis Vs Numbness Blurred vision Vs Diplopia Dizziness Vs Weakness Vs Fatigue Blackout: Loss of Conciousness Vs Loss of Vision Vs Confusion Dysphasias Vs Dysarthrias
  • 43. Data from Chief Complaints and Presenting Illness • What and Where is the Lesion?
  • 44. Data from Chief Complaints and Presenting Illness • What and Where is the Lesion? • If Uninterpretable- Recollect Data
  • 45. Generalized Symptoms • Headache • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure
  • 46. Generalized Symptoms • Headache • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure
  • 47. Generalized Symptoms • Headache • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure
  • 48. Generalized Symptoms • Headache • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure
  • 49. Generalized Symptoms • Headache • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure
  • 50. Generalized Symptoms • Headache • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure
  • 51. Generalized Symptoms • Headache • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure
  • 52. Focal Symptoms • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar Symptoms(Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 53. Focal Symptoms • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar Symptoms(Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 54. Focal Symptoms • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar Symptoms(Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 55. Focal Symptoms • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar Symptoms(Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 56. Focal Symptoms • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar Symptoms(Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 57. Focal Symptoms • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar Symptoms(Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 58. Focal Symptoms • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar Symptoms(Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 59. Focal Symptoms • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar Symptoms(Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 60. Combinations • Headache/ Facial Pain • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar symptoms (Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 61. Combinations • Headache/ Facial Pain • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar symptoms (Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 62. Combinations • Headache/ Facial Pain • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar symptoms (Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 63. Combinations • Headache/ Facial Pain • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar symptoms (Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 64. Combinations • Headache/ Facial Pain • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar symptoms (Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 65. Combinations • Headache/ Facial Pain • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar symptoms (Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 66. Combinations • Headache/ Facial Pain • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar symptoms (Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 67. Combinations • Headache/ Facial Pain • Altered Consciousness • Behavioral Changes • Memory Disturbances • Intellectual Decline • Generalized Weakness • Generalized Seizure • Focal Seizure • Speech and Phonation • Cranial Nerves Deficits • Motor System(UMN/ LMN) • Sensory System(DC/ ST) • Cerebellar symptoms (Midline/ Lateral) • Extra -pyramidal Symptoms • Autonomic Symptoms (Sympathetic/ PS)
  • 68. Common Patterns • Coma • Dementias • III, IV & VI • V & VII Cranial Nerves • Lower Cranial Nerves • Hemiplegia • Paraplegia • Extrapyramidal Disorders • Cerebellar • Polyneuropathy • Peripheral Neuropathy • Neuromuscular Disorders • Muscle Diseases
  • 69. Common Patterns • Coma • Dementias • III, IV & VI • V & VII Cranial Nerves • Lower Cranial Nerves • Hemiplegia • Paraplegia • Extrapyramidal Disorders • Cerebellar • Polyneuropathy • Peripheral Neuropathy • Neuromuscular Disorders • Muscle Diseases
  • 70. Common Patterns • Coma • Dementias • III, IV & VI • V & VII Cranial Nerves • Lower Cranial Nerves • Hemiplegia • Paraplegia • Extrapyramidal Disorders • Cerebellar • Polyneuropathy • Peripheral Neuropathy • Neuromuscular Disorders • Muscle Diseases
  • 71. Common Patterns • Coma • Dementias • III, IV & VI • V & VII Cranial Nerves • Lower Cranial Nerves • Hemiplegia • Paraplegia • Extrapyramidal Disorders • Cerebellar • Polyneuropathy • Peripheral Neuropathy • Neuromuscular Disorders • Muscle Diseases
  • 72. Common Patterns • Coma • Dementias • III, IV & VI • V & VII Cranial Nerves • Lower Cranial Nerves • Hemiplegia • Paraplegia • Extrapyramidal Disorders • Cerebellar • Polyneuropathy • Peripheral Neuropathy • Neuromuscular Disorders • Muscle Diseases
  • 73. Common Patterns • Coma • Dementias • III, IV & VI • V & VII Cranial Nerves • Lower Cranial Nerves • Hemiplegia • Paraplegia • Extrapyramidal Disorders • Cerebellar • Polyneuropathy • Peripheral Neuropathy • Neuromuscular Disorders • Muscle Diseases
  • 74. Common Patterns • Coma • Dementias • III, IV & VI • V & VII Cranial Nerves • Lower Cranial Nerves • Hemiplegia • Paraplegia • Extrapyramidal Disorders • Cerebellar • Polyneuropathy • Peripheral Neuropathy • Neuromuscular Disorders • Muscle Diseases
  • 75. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 76. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 77. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 78. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 79. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 80. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 81. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 82. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 83. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 85. Common Etiologies • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 87. 20 year Female; Headache X 2 days • Started at the back of the head spread all over • Sudden onset, crescendo pattern • Aggravated by coughing/ straining • No relief with NSAID • Associated with vomiting • No fever
  • 88. 20 year Female; Headache X 2 days • Had a generalized seizure in the bathroom, following which she did not regain consciousness for several hours- to days
  • 89. 20 year male; Headache X 2 days • Started on left side around the eyes, spread all over, Throbbing character • More in the evening • Aggravated by coughing/ straining • Partial relief with Aspirin • Associated with vomiting, noise intolerance, photophobia • No fever • Exam around corner, studying late, missed a meal • Similar headache in the past
  • 90. 40 Year old Executive; Headache X 3 weeks • Insidious onset, frontal region • More in the morning, Better by evening, • Partial relief with NSAIDS • Has been vomiting for past week effortlessly, • Weakness and stiffness of right upper limb noticeable for past few days • Wife reports a mild change in personality
  • 91. List of Problems Integrate History and Physical Exam First • Anatomical localization of lesion • Focal, multifocal or diffuse • Nucleus, tract or system disorder • CNS/ PNS or both? Second Cause of Lesion • Congenital/ inherited • Trauma • Tumor • Infection • Vascular • Metabolic/ Toxic/Nutritional • Degenerative/ Demyelinating • Idiopathic • Psychogenic
  • 92. Case1 : 25 year old soldier on leave Brought by relatives • Weakness of all 4 limbs X 5 days • Difficulty in breathing X 1 day • Noticed weakness of left LL on waking up.A few hours later similar complaint started in the right LL. A day later same problem developed in the upper limbs too. There has been rapid worsening. For the past 2 days he is unable to get up from the bed. Since yesterday he has developed difficulty in breathing. No cough…… • No sensory complaints. No suggestion of cranial nerve involvement/ seizures/ bowel & bladder disturbances • Diarrheal illness 2 weeks ago
  • 93. 25 year old soldier on leave • Clinically- T 99 degree F • Pulse 120/ min • BP 160/100 • Tachypnea- shallow respiration • Chest expansion 1 cm • Wasting • Decreased tone • Grade 0 to 2 power • Areflexia- all 4 limbs
  • 94. 25 year old soldier • Where & • What is the lesion ?
  • 95. 25 year old soldier • Acute, Asymmetric, Areflexic, Quadriparesis (Polyradiculopathy) • Post infective Gullian Barre Syndrome
  • 96. 25 year old soldier • What are the urgencies?
  • 97. 25 year old soldier • Respiratory Neuromuscular Failure • Dysautonomia
  • 98. Case 2: 30 year old lady • Burning pain like a band on the right side of the chest X 2 days • Few blisters over the same area- this morning • What? • Where?
  • 99. Case 3: 45 year old Hypertensive • Weakness left side of body X 6 hours • Sudden onset, while sitting at the table, progressed rapidly over 1 hour, no improvement • Where is the lesion? • What is the lesion?
  • 100. Case 1: Female 35 Ys SLE on Prednisolone 5 mg/ day • Acute R Hemiparesis X 1 day • CT Brain Acute R MCA Infarct • EKG at admission: AF with Rapid Vent Rate, CHF • Summary of Problem list: – Acute Stroke – AF with CHF – SLE on Prednisolone
  • 101. Organise your thoughts Acute Stroke AF with CHF SLE on Prednisolone
  • 102. Lateral Thinking Ac Stroke from AF/ Other problems in SLE Ac Stroke from AF/AF From Carditis/ Carditis from SLE Ac Stroke from other causes/ SLE ass. Stroke (Vasculitis, APL)/ Treatment ass. stroke- infection AF due to stroke
  • 103. Exercise your thought processes • Bedside discussions • Study case records
  • 104. Equipment Needed • Pen Light/ Scope • Knee Hammer • 128 &n 512 Tuning Forks • Cotton Swabs • Pins • Calliper/ Divider • Tubes for hot and cold water • Stoppered containers for odour/ taste •