Approach to the patient with neurologic disease gk


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Approach to the patient with neurologic disease gk

  1. 1. Approach to the Patient with NeurologicDisease
  2. 2. Questions to be answered!!!• Is there a lesion• Where is the lesion• What is the lesion• Is there treatment
  3. 3. Locate the Lesion(S)The first priority is to identify the region of the nervoussystem that is likely to be responsible for the symptoms.Can the disorder be mapped to one specific location, is itmultifocal, or is a diffuse process present? Are thesymptoms restricted to the nervous system, or do theyarise in the context of a systemic illness? Is the problem inthe central nervous system (CNS), the peripheral nervoussystem (PNS), or both? If in the CNS, is the cerebralcortex, basal ganglia, brainstem, cerebellum, or spinal cordresponsible? Are the pain-sensitive meninges involved? Ifin the PNS, could the disorder be located in peripheralnerves and, if so, are motor or sensory nerves primarilyaffected, or is a lesion in the neuromuscular junction ormuscle more likely?
  4. 4. Symptoms in nervous system could be dueto functional or structural derangement of Upper motor neuron –up to Cranial Nuclei and Anterior Horn Cell. Lower motor neuron – Cranial Nuclei and Anterior Horn cell downwards.
  5. 5. Upper motor neuron Lower motor neuron Movement paralysis  Muscle paralysis Reflex movement  Both absent present voluntary absent.  Hypotonia Hypertonia/ Spasticity  Wasting, fasciculations Disuse atrophy  Both lost Superficial reflexes lost deep exaggerated.
  6. 6. Symptoms localisations They could be :- I II  Acute  Progressive  Subacute  Regressive  Chronic  Remitting & relapsing
  7. 7. Layers of Cerebral Cortex A Natural Neural NetworkMind is literally life-like. The Universe and Life are literally mind-like. " Peter Winiwarter (2008). Network Nature.
  8. 8. Mind is literally life-like. The Universe and Life are literally mind- like”. Peter Winiwarter (2008). Network Nature.
  9. 9. The Nervous System• Major division - Central vs. Peripheral• Central or CNS- brain and spinal cord• Peripheral- nerves connecting CNS to muscles and organs Central Nervous System Peripheral Nervous System
  10. 10. Peripheral Nervous System• 3 kinds of neurons connect CNS to the body Brain Spinal – sensory Cord – motor – interneurons Nerves• Motor - CNS to muscles and organs• Sensory - sensory receptors to CNS• Interneurons: Connections Within CNS
  11. 11. Peripheral nervous system Peripheral Nervous System Skeletal Autonomic (Somatic) Sympathetic Parasympathetic
  12. 12. Central Nervous System Brain Spinal• Brain and Spinal Cord Cord
  13. 13. Gray and White Matter• Gray matter = neuron cell bodies, dendrites, and synapses – forms cortex over cerebrum and cerebellum – forms nuclei deep within brain• White matter = bundles of axons – forms tracts that connect parts of brain
  14. 14. • Longitudinal fissureLobes and Fissures (green) • Frontal lobe • Central sulcus (yellow) – precentral & postcentral gyrus • Parietal lobe • Parieto-occipital sulcus • Occipital lobe • Lateral sulcus (blue) • Temporal lobe • Insula
  15. 15. Functional Regions of Cerebral Cortex
  16. 16. Clinical method of Neurology• Series of steps• History• Examination
  17. 17. History• Chief complaints• Temporal profile - Onset, Progression, Duration• Personal, Family, Social History
  18. 18. Objective of History• Possible Anatomical and Etiological Diagnosis e.g. Right Hemiplegia with Aphasia Tingling sensation in the index and middle finger.• Hypothesis generation
  19. 19. Detailed NeurologicalExamination• To confirm or refute the hypotheses of history• To localize the lesion• Anatomical and etiological diagnosis
  20. 20. The Diagnostic Law• The Law of ParsimonyOnly one EtiologyOnly one Lesion• Occams RazorThe simplest and the most straightexplanation is the correct.
  21. 21. Differential Diagnosis• Most likely to Least likely• Epidemiology.• Treatable Disease
  22. 22. Investigations to ConfirmDiagnosis• Hematological, Biochemical,• Neuroimaging, Neurophysiology,• Histopathology, Genetic studies.
  23. 23. History• Patient Intelligence, Language, Social, Cultural• Neurologist Personality, Situation
  24. 24. Chief complaints• Exact meaning e.g. dizziness/chakkar, ? Is it true vertigo• Precise onset• Progression
  25. 25. Other History• Personal History• Family History, Pedigree charting• Previous Illness
  26. 26. Review of other Neurologic Systems • Titrate as per history • HMF • Titrate using several tests • Cranial Nerves from easy to difficult • Motor • Tailor to the clinicalTEST FUNCTIONS OF DIFFERENT PARTS OF THE NERVOUS SYSTEM • Reflexes situation Normal Function or Abnormal signs • 2 minutes for a comatose • SensoryPRESENCE OF ABNORMAL SIGNS (To confirm a lesion) LOOK FOR OR emergency patient • Gait, Coordination OF SIGNS (To refute a lesion) ABSENCE • 1 hour for unusual patient • Involuntary Movements in the office • Focused examination for Headache
  27. 27. HMFAttention, Comprehension, level ofconsciousness/alertness, CooperationAttention - Spell WORLD, months of year,digit span forward & backwardComprehension – During historyAlertness – Awake , drowsy, lethargicInvolves Language, memory, fund of knowledge,Education, cooperation
  28. 28. • Orientation• Time, place, person• Tests attention, language, recent and long term memory
  29. 29. Memory• Memory • Remote memory• 3 minute recall • Historical events• 3 objects, short story • Personal events• Check registration • Frontal• Recall after 3 minutes lobe, cerebellum• Papez circuit
  30. 30. Papez Circuit
  31. 31. Amnesia• Anterograde Amnesia • Mesial Temporal Inability to form new lesions memories • MTLS• Retrograde Amnesia • Herpes Encephalitis Inability to recollect • Head Injury earlier events • PCA infarcts • Alzheimers dementia • Thalamic Lesions
  32. 32. Language• Spontaneous Speech• Comprehension• Naming• Reading• Repetition• Writing
  33. 33. Gerstmann’s Syndrome• Calculations• Right-Left Confusion• Finger Agnosia• AgraphiaDominant Parietal lobe(inferior parietal lobule)
  34. 34. Apraxia• Apraxia -inability to follow • Ideomotor apraxia a motor command that is • Ideational apraxia not due to a primary • Constructional apraxia motor deficit or a language impairment • Dressing apraxia• Impaired higher-order • Ocular apraxia planning, programming or conceptualization of the motor task• Pretend to comb you hair• Pretend to strike a match and blow it out
  35. 35. Hemineglect• Inability to pay attention to or notice stimuli from one-half of the visual field• While copying a drawing, omit the material on the left• eat only the food on the right half of the plate, leaving that on the left.
  36. 36. Hemineglect• Nondominant Parietal • Anosognosia Lobe • Lack of awarness or• Abnormality in denial of the attention/Neglect to deficit, hemiplegia one side of the • Antons syndrome – universe denial of cortical (vision, sensation and blindness power are normal)
  37. 37. Frontal Lobe Tests
  38. 38. Frontal Lobe Tests• Abstract thinking and Logic If Mary is taller than Jane, and Jane is taller than Ann, whos the tallest?" "Dont cry over spilled milk"?• Delusions and Hallucinations• Mood Depressed, Anxious, Maniac
  39. 39. Cranial nerves• Olfactory Test smell of coffee, soap in each nostril (Olfactory groove meningioma)
  40. 40. Optic Nerve • Visual Acuity • Color Vision (Red desaturation) • Visual field by confrontation • Visual extinction • Menace reflex
  41. 41. Visual Field Pupillary light reflex & Swinging FlashlightVisual acuity
  42. 42. Cranial Nerves III, IV, VISaccadesPursuitDiplopiaConvergenceNystagmusOptokinetic nystagmusOculocephalic or Dolls Eye reflex
  43. 43. Extraocular Muscle Palsy Left VI Left III Left IV
  44. 44. Trigeminal Nerve• Facial Sensation• Corneal reflex• Massetors, Pterygoid, Temporalis muscles
  45. 45. Facial Nerve
  46. 46. Prior Reports and Opinions• Reviews earlier evaluation• Forms New Hypothesis• Critical thinking
  47. 47. Screening NeurologicalExamination• Mental Status• Cranial Nerves• Motor System• Sensory System• Reflexes• Gait• Rombergs Test• Involuntary movements
  48. 48. Willis pathological Diagnosis• Hereditary• Congenital• Traumatic• Inflammatory• Vascular• Neoplastic• Degenerative• Metabolic• Autoimmune• Nutritional
  49. 49. Pathways in NeurologicalDiagnosis• Hypotheticodeductive Method• Pattern recognition
  50. 50. Hypotheticodeductive system• Observations early on• Hypothesis (Broad and Vague)• Conclusions• Revision of conclusion• Alternate hypothesis• Rapid and multiple hypothesis
  51. 51. Pattern Recognition• Experts method• Weigh and structure data• What is most significant• Structure data to make sense and form known pattern• Look for key features• Each symptom has limited possibilities• Ask questions which have distinguishing power• Odd feature may refute hypothesis
  52. 52. Thank You