Approach to the patient with neurologic disease gk
Approach to the Patient with NeurologicDisease
Questions to be answered!!!• Is there a lesion• Where is the lesion• What is the lesion• Is there treatment
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?
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.
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.
Symptoms localisations They could be :- I II Acute Progressive Subacute Regressive Chronic Remitting & relapsing
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. www.bordalierinstitute.com
Mind is literally life-like. The Universe and Life are literally mind- like”. Peter Winiwarter (2008). Network Nature. www.bordalierinstitute.com
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
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
Peripheral nervous system Peripheral Nervous System Skeletal Autonomic (Somatic) Sympathetic Parasympathetic
Central Nervous System Brain Spinal• Brain and Spinal Cord Cord
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
Chief complaints• Exact meaning e.g. dizziness/chakkar, ? Is it true vertigo• Precise onset• Progression
Other History• Personal History• Family History, Pedigree charting• Previous Illness
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
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
• Orientation• Time, place, person• Tests attention, language, recent and long term memory
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
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
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.
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)
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
Cranial nerves• Olfactory Test smell of coffee, soap in each nostril (Olfactory groove meningioma)
Optic Nerve • Visual Acuity • Color Vision (Red desaturation) • Visual field by confrontation • Visual extinction • Menace reflex
Visual Field Pupillary light reflex & Swinging FlashlightVisual acuity
Cranial Nerves III, IV, VISaccadesPursuitDiplopiaConvergenceNystagmusOptokinetic nystagmusOculocephalic or Dolls Eye reflex
Extraocular Muscle Palsy Left VI Left III Left IV
Pathways in NeurologicalDiagnosis• Hypotheticodeductive Method• Pattern recognition
Hypotheticodeductive system• Observations early on• Hypothesis (Broad and Vague)• Conclusions• Revision of conclusion• Alternate hypothesis• Rapid and multiple hypothesis
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