Approach to neurological disorders

transcript

Symptomatologyof Neurological

Disorders

III Term

Introductory Lecture Series

Dr C Khati

Department of Medicine

Thinking like a NeurologistIs it Different?

Is it Difficult?

Always Ask

1. Where is the lesion?

Always Ask

2. What is the lesion?

Always Ask

Neuro-Anatomical Diagnosis

Always Ask

Neuro-Anatomical Diagnosis

Etiological Diagnosis

Complex Brain Processing

HISTORY

EXAMINATION

Task and GoalTask 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?

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 SymptomsOnset, Duration and Progression

Some Disability

Symptomatic Approach IDisorder Analysis

Consciousness Level Content

Consciousness

Mental Functions Memory IntelligencePersonality BehaviorDementia

Consciousness

Mental Functions

Higher Cortical Function Apraxia AgnosiaAphasia Others

Consciousness

Mental Functions

Higher Cortical Function

Visual Visual Loss Diplopia

Symptomatic Approach IIStructure/ System Disorder

Language and Speech DysarthriaDysphasia

Symptomatic Approach IIStructure/ System Disorder

Language and Speech

Lower Cranial Nerves Deafness/ tinnitusVertigoBalance/ staggeringSwallowingVoice change

Symptomatic Approach IIISystem Disorder

Sensory •Pain Headache Facial PainOther Pain-

•Numbness and Tingling•Others

Sensory

Motor •Weakness/ Stiffness•Wasting•Fasciculations•Movement Disorder

Sphincter

Sensory

Sphincter •Incontinence•Retention

Sensory •Pain Headache Facial PainOther Pain-

•Numbness and Tingling•Others

Sphincter

Sensory

Motor •Weakness/ Stiffness•Wasting•Fasciculations•Movement Disorder

Sphincter

Sensory

Sphincter •Incontinence•Retention

Symptomatic Approach IV

Temporal Profile Condition

Episodic •Intermittent•Remittent

•Seizure•Syncope•TIA•Migraine(Abnormal Movement)

Continuous •Static•Progressive•Improving

Episodic •Intermittent•Remittent

Episodic •Intermittent•Remittent ?

•Seizure•Syncope•TIA•Migraine•(Abnormal Movement)

Episodic •Intermittent•Remittent-Demyelination

Present Illness

• Symptoms

Clarify SymptomsOnset, Duration and Progression

Some Disability

Data Collection – Skilled Task

Chief Complaints First Step- Get the Right Data

Pattern Recognition Group of SymptomsMode of Onset

Common Mis- interpretations

ParalysisVs Numbness

Blurred visionVs Diplopia

Dizziness Vs Weakness Vs Fatigue

Blackout:Loss of ConciousnessVs Loss of Vision Vs Confusion

DysphasiasVs 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

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

• Focal Seizure

• Cerebellar symptoms (Midline/ Lateral)

Combinations

• Focal Seizure

Combinations

• Focal Seizure

Combinations

• Focal Seizure

Combinations

• Focal Seizure

Combinations

• Focal Seizure

Combinations

• Focal Seizure

Combinations

• Focal Seizure

Common Patterns

• Coma

• Dementias

• III, IV & VI

• V & VII Cranial Nerves

• Lower Cranial Nerves

• Hemiplegia

• Paraplegia

• ExtrapyramidalDisorders

• Cerebellar

• Polyneuropathy

• Peripheral Neuropathy

• Neuromuscular Disorders

• Muscle Diseases

Common Patterns

• Coma

• Dementias

• III, IV & VI

• Hemiplegia

• Paraplegia

• Cerebellar

• Polyneuropathy

• Muscle Diseases

Common Patterns

• Coma

• Dementias

• III, IV & VI

• Hemiplegia

• Paraplegia

• Cerebellar

• Polyneuropathy

• Muscle Diseases

Common Patterns

• Coma

• Dementias

• III, IV & VI

• Hemiplegia

• Paraplegia

• Cerebellar

• Polyneuropathy

• Muscle Diseases

Common Patterns

• Coma

• Dementias

• III, IV & VI

• Hemiplegia

• Paraplegia

• Cerebellar

• Polyneuropathy

• Muscle Diseases

Common Patterns

• Coma

• Dementias

• III, IV & VI

• Hemiplegia

• Paraplegia

• Cerebellar

• Polyneuropathy

• Muscle Diseases

Common Patterns

• Coma

• Dementias

• III, IV & VI

• Hemiplegia

• Paraplegia

• Cerebellar

• Polyneuropathy

• Muscle Diseases

Common Etiologies

• Congenital/ inherited

• Trauma

• Tumor

• Infection

• Vascular

• Metabolic/ Toxic/Nutritional

• Degenerative/ Demyelinating

• Idiopathic

• Psychogenic

Common Etiologies

• Trauma

• Tumor

• Infection

• Vascular

• Idiopathic

• Psychogenic

Common Etiologies

• Trauma

• Tumor

• Infection

• Vascular

• Idiopathic

• Psychogenic

Common Etiologies

• Trauma

• Tumor

• Infection

• Vascular

• Idiopathic

• Psychogenic

Common Etiologies

• Trauma

• Tumor

• Infection

• Vascular

• Idiopathic

• Psychogenic

Common Etiologies

• Trauma

• Tumor

• Infection

• Vascular

• Idiopathic

• Psychogenic

Common Etiologies

• Trauma

• Tumor

• Infection

• Vascular

• Idiopathic

• Psychogenic

Common Etiologies

• Trauma

• Tumor

• Infection

• Vascular

• Idiopathic

• Psychogenic

Common Etiologies

• Trauma

• Tumor

• Infection

• Vascular

• Idiopathic

• Psychogenic

Analysis

• Pattern Recognition

• Context Recognition

Common Etiologies

• Trauma

• Tumor

• Infection

• Vascular

• 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 regainconsciousness 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 ProblemsIntegrate History and Physical Exam

• Anatomical localization of lesion

• Focal, multifocal or diffuse

• Nucleus, tract or system disorder

• CNS/ PNS or both?

SecondCause of Lesion• Congenital/ inherited• Trauma• Tumor• Infection• Vascular• Metabolic/ Toxic/Nutritional• Degenerative/

Demyelinating• Idiopathic• Psychogenic

Case1 : 25 year old soldier on leaveBrought 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 CHFSLE on

Prednisolone

Lateral Thinking

Ac Stroke from AF/ Other problems in

Ac Stroke from AF/AF

From Carditis/ Carditis from

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•

Approach to neurological disorders

Health & Medicine