Approach to neurological disorders
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Transcript of Approach to neurological disorders
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?
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 GoalTask Goal
Chief Complaints Anatomical Localization
Task and GoalTask Goal
Chief Complaints Anatomical Localization
History Taking Etiologies
Task and GoalTask Goal
Chief Complaints Anatomical Localization
History Taking Etiologies
Neuro Examination Confirmation of Anatomical Localization
Task and GoalTask Goal
Chief Complaints Anatomical Localization
History Taking Etiologies
Neuro Examination Confirmation of Anatomical Localization
Possible Diseases Review of Patient Specific Features
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?
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
Onset
Some Disability
Symptomatic Approach IDisorder Analysis
Consciousness Level Content
Symptomatic Approach IDisorder Analysis
Consciousness
Mental Functions Memory IntelligencePersonality BehaviorDementia
Symptomatic Approach IDisorder Analysis
Consciousness
Mental Functions
Higher Cortical Function Apraxia AgnosiaAphasia Others
Symptomatic Approach IDisorder Analysis
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
Symptomatic Approach IIISystem Disorder
Sensory
Motor •Weakness/ Stiffness•Wasting•Fasciculations•Movement Disorder
Sphincter
Symptomatic Approach IIISystem Disorder
Sensory
Motor
Sphincter •Incontinence•Retention
Symptomatic Approach IIISystem Disorder
Sensory •Pain Headache Facial PainOther Pain-
•Numbness and Tingling•Others
Motor
Sphincter
Symptomatic Approach IIISystem Disorder
Sensory
Motor •Weakness/ Stiffness•Wasting•Fasciculations•Movement Disorder
Sphincter
Symptomatic Approach IIISystem 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 SymptomsOnset, Duration and Progression
Onset
Some Disability
Data Collection – Skilled Task
Chief Complaints First Step- Get the Right Data
Pattern Recognition Group of SymptomsMode of Onset
Data Collection – Skilled Task
Chief Complaints First Step- Get the Right Data
Pattern Recognition Group of SymptomsMode of Onset
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
Common Mis- interpretations
ParalysisVs Numbness
Blurred visionVs Diplopia
Dizziness Vs Weakness Vs Fatigue
Blackout:Loss of ConciousnessVs Loss of Vision Vs Confusion
DysphasiasVs Dysarthrias
Common Mis- interpretations
ParalysisVs Numbness
Blurred visionVs Diplopia
Dizziness Vs Weakness Vs Fatigue
Blackout:Loss of ConciousnessVs Loss of Vision Vs Confusion
DysphasiasVs Dysarthrias
Common Mis- interpretations
ParalysisVs Numbness
Blurred visionVs Diplopia
Dizziness Vs Weakness Vs Fatigue
Blackout:Loss of ConciousnessVs Loss of Vision Vs Confusion
DysphasiasVs Dysarthrias
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
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
• ExtrapyramidalDisorders
• Cerebellar
• Polyneuropathy
• Peripheral Neuropathy
• Neuromuscular Disorders
• Muscle Diseases
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
• 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
• 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
• 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
• 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
• V & VII Cranial Nerves
• Lower Cranial Nerves
• Hemiplegia
• Paraplegia
• ExtrapyramidalDisorders
• 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 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
First
• 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
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•