Approach to the patient with neurologic disease gk
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Transcript of Approach to the patient with neurologic disease gk
Approach to the Patient with Neurologic Disease
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 nervous system that is likely to be responsible for the symptoms. Can the disorder be mapped to one specific location, is it multifocal, or is a diffuse process present? Are the symptoms restricted to the nervous system, or do they arise in the context of a systemic illness? Is the problem in the central nervous system (CNS), the peripheral nervous system (PNS), or both? If in the CNS, is the cerebral cortex, basal ganglia, brainstem, cerebellum, or spinal cord responsible? Are the pain-sensitive meninges involved? If in the PNS, could the disorder be located in peripheral nerves and, if so, are motor or sensory nerves primarily affected, or is a lesion in the neuromuscular junction or muscle more likely?
Symptoms in nervous system could be due
to 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
Movement paralysis Reflex movement
present voluntary absent.
Hypertonia/ Spasticity Disuse atrophy Superficial reflexes lost
deep exaggerated.
Lower motor neuron Muscle paralysis Both absent
Hypotonia Wasting, fasciculations Both lost
Symptoms localisations
I Acute Subacute Chronic
IIProgressiveRegressiveRemitting &
relapsing
They could be :-
A Natural Neural NetworkLayers of Cerebral Cortex
Mind 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– sensory– motor– interneurons
• Motor - CNS to muscles and organs
• Sensory - sensory receptors to CNS
• Interneurons: Connections Within CNS
SpinalCord
Brain
Nerves
Peripheral nervous system
Skeletal(Somatic)
Sympathetic Parasympathetic
Autonomic
Peripheral Nervous System
Central Nervous System
• Brain and Spinal CordSpinalCord
Brain
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
Lobes and Fissures • Longitudinal fissure (green)
• Frontal lobe• Central sulcus (yellow)
– precentral & postcentral gyrus
• Parietal lobe• Parieto-occipital sulcus• Occipital lobe• Lateral sulcus (blue)• Temporal lobe• Insula
Functional Regions of Cerebral Cortex
Clinical method of Neurology
• Series of steps
• History
• Examination
History
• Chief complaints
• Temporal profile - Onset, Progression,
Duration
• Personal, Family, Social History
Objective of History
• Possible Anatomical and Etiological Diagnosis
e.g. Right Hemiplegia with Aphasia
Tingling sensation in the index and middle finger.
• Hypothesis generation
Detailed Neurological Examination
• To confirm or refute the hypotheses of history
• To localize the lesion
• Anatomical and etiological diagnosis
The Diagnostic Law
• The Law of Parsimony
Only one EtiologyOnly one Lesion
• Occams Razor
The simplest and the most straightexplanation is the correct.
Differential Diagnosis
• Most likely to Least likely
• Epidemiology.
• Treatable Disease
Investigations to Confirm Diagnosis• Hematological, Biochemical,
• Neuroimaging, Neurophysiology,
• Histopathology, Genetic studies.
History
• Patient
Intelligence, Language, Social, Cultural
• Neurologist
Personality, Situation
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• H M F• Cranial Nerves• Motor• Reflexes• Sensory• Gait, Coordination • Involuntary Movements
• Titrate as per history • Titrate using several tests
from easy to difficult• Tailor to the clinical situation• 2 minutes for a comatose
emergency patient• 1 hour for unusual patient
in the office• Focused examination for
Headache
TEST FUNCTIONS OF DIFFERENT PARTS OF THE NERVOUS SYSTEMNormal Function or Abnormal signs
LOOK FOR PRESENCE OF ABNORMAL SIGNS (To confirm a lesion) OR
ABSENCE OF SIGNS (To refute a lesion)
HMF
Attention, Comprehension, level ofconsciousness/alertness, CooperationAttention - Spell WORLD, months of year, digit span forward & backward Comprehension – During historyAlertness – Awake , drowsy, lethargic
Involves Language, memory, fund of knowledge, Education, cooperation
• Orientation• Time, place, person • Tests attention, language, recent and long
term memory
• Memory• 3 minute recall• 3 objects, short story• Check registration• Recall after 3 minutes• Papez circuit
• Remote memory• Historical events• Personal events• Frontal lobe, cerebellum
Memory
Papez Circuit
Amnesia
• Anterograde Amnesia
Inability to form new memories• Retrograde Amnesia
Inability to recollect earlier events
• Mesial Temporal lesions• MTLS• Herpes Encephalitis• Head Injury• PCA infarcts• Alzheimer's dementia• Thalamic Lesions
Language• Spontaneous Speech• Comprehension• Naming• Reading • Repetition• Writing
Gerstmann’s Syndrome • Calculations• Right-Left Confusion• Finger Agnosia• Agraphia
Dominant Parietal lobe
(inferior parietal lobule)
Apraxia
• Apraxia -inability to follow a motor command that is not due to a primary motor deficit or a language impairment
• Impaired higher-order planning, programming or conceptualization of the motor task
• Pretend to comb you hair • Pretend to strike a match and blow it out
• Ideomotor apraxia • Ideational apraxia• Constructional apraxia• Dressing apraxia• Ocular apraxia
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 Lobe• Abnormality in attention/Neglect to one
side of the universe (vision, sensation and power are normal)
• Anosognosia• Lack of awarness or denial of the deficit,
hemiplegia• Antons syndrome – denial of cortical
blindness
Frontal Lobe Tests
Frontal Lobe Tests
• Abstract thinking and Logic
If Mary is taller than Jane, and Jane is taller than Ann, who's the tallest?"
"Don't 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
Visual acuity
Pupillary light reflex &Swinging Flashlight
Cranial Nerves III, IV, VI
SaccadesPursuitDiplopiaConvergenceNystagmusOptokinetic nystagmusOculocephalic or Dolls Eye reflex
Extraocular Muscle Palsy
Left VI
Left III
Left IV
Trigeminal Nerve
• Facial Sensation• Corneal reflex• Massetors, Pterygoid,
Temporalis muscles
Facial Nerve
Prior Reports and Opinions
• Reviews earlier evaluation
• Forms New Hypothesis
• Critical thinking
Screening Neurological Examination• Mental Status• Cranial Nerves• Motor System• Sensory System• Reflexes• Gait• Rombergs Test• Involuntary movements
Willis pathological Diagnosis
• Hereditary• Congenital• Traumatic• Inflammatory• Vascular• Neoplastic • Degenerative• Metabolic• Autoimmune• Nutritional
Pathways in Neurological Diagnosis
• 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
Thank You