Approach to Neurological Disease

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Information about Approach to Neurological Disease

Published on May 27, 2010

Author: neurology1


Approach to Neurological Disease : Approach to Neurological Disease Dr Rahul T Chakor Associate Prof Dept of Neurology T N Medical College & B Y L Nair Hospital Mumbai. Neurology is Simple and Straightforward : Neurology is Simple and Straightforward Nervous System is Highly Complex Questions to be answered!!! : Questions to be answered!!! Is there a lesion Where is the lesion What is the lesion Is there treatment Slide 5: 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. Slide 6: 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 : Symptoms localisations I Acute Subacute Chronic II Progressive Regressive Remitting & relapsing They could be :- Slide 8: A Natural Neural Network Layers of Cerebral Cortex Mind is literally life-like. The Universe and Life are literally mind-like. "                                                                 Peter Winiwarter (2008). Network Nature. Slide 9: Mind is literally life-like. The Universe and Life are literally mind- like”.                                                              Peter Winiwarter (2008). Network Nature. The Nervous System : The Nervous System Major division - Central vs. Peripheral Central or CNS- brain and spinal cord Peripheral- nerves connecting CNS to muscles and organs 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 Peripheral nervous system : Peripheral nervous system S k e l e t a l ( S o m a t i c ) S y m p a t h e t i c P a r a s y m p a t h e t i c A u t o n o m i c P e r i p h e r a l N e r v o u s S y s t e m Central Nervous System : Central Nervous System Brain and Spinal Cord Gray and White Matter : 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 : 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 : Functional Regions of Cerebral Cortex Clinical method of Neurology : Clinical method of Neurology Series of steps History Examination History : History Chief complaints Temporal profile - Onset, Progression, Duration Personal, Family, Social History Objective of 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 : Detailed Neurological Examination To confirm or refute the hypotheses of history To localize the lesion Anatomical and etiological diagnosis The Diagnostic Law : The Diagnostic Law The Law of Parsimony Only one Etiology Only one Lesion Occams Razor The simplest and the most straight explanation is the correct. Differential Diagnosis : Differential Diagnosis Most likely to Least likely Epidemiology. Treatable Disease Investigations to Confirm Diagnosis : Investigations to Confirm Diagnosis Hematological, Biochemical, Neuroimaging, Neurophysiology, Histopathology, Genetic studies. History : History Patient Intelligence, Language, Social, Cultural Neurologist Personality, Situation Chief complaints : Chief complaints Exact meaning e.g. dizziness/chakkar, ? Is it true vertigo Precise onset Progression Other History : Other History Personal History Family History, Pedigree charting Previous Illness Review of other Neurologic Systems : 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 SYSTEM Normal Function or Abnormal signs LOOK FOR PRESENCE OF ABNORMAL SIGNS (To confirm a lesion) OR ABSENCE OF SIGNS (To refute a lesion) HMF : HMF Attention, Comprehension, level of consciousness/alertness, Cooperation Attention - Spell WORLD, months of year, digit span forward & backward Comprehension – During history Alertness – Awake , drowsy, lethargic Involves Language, memory, fund of knowledge, Education, cooperation Slide 30: Orientation Time, place, person Tests attention, language, recent and long term memory 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 : Papez Circuit Amnesia : 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 Slide 34: Language Spontaneous Speech Comprehension Naming Reading Repetition Writing Slide 35: Gerstmann’s Syndrome Calculations Right-Left Confusion Finger Agnosia Agraphia Dominant Parietal lobe (inferior parietal lobule) Apraxia : 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 : 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 : 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 Slide 41: Frontal Lobe Tests 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 : Cranial nerves Olfactory Test smell of coffee, soap in each nostril (Olfactory groove meningioma) Optic Nerve : Optic Nerve Visual Acuity Color Vision (Red desaturation) Visual field by confrontation Visual extinction Menace reflex Slide 45: Visual Field Visual acuity Pupillary light reflex & Swinging Flashlight Slide 46: Cranial Nerves III, IV, VI Saccades Pursuit Diplopia Convergence Nystagmus Optokinetic nystagmus Oculocephalic or Dolls Eye reflex Extraocular Muscle Palsy : Extraocular Muscle Palsy Left VI Left III Left IV Trigeminal Nerve : Trigeminal Nerve Facial Sensation Corneal reflex Massetors, Pterygoid, Temporalis muscles Facial Nerve : Facial Nerve Prior Reports and Opinions : Prior Reports and Opinions Reviews earlier evaluation Forms New Hypothesis Critical thinking Screening Neurological Examination : Screening Neurological Examination Mental Status Cranial Nerves Motor System Sensory System Reflexes Gait Rombergs Test Involuntary movements Willis pathological Diagnosis : Willis pathological Diagnosis Hereditary Congenital Traumatic Inflammatory Vascular Neoplastic Degenerative Metabolic Autoimmune Nutritional Pathways in Neurological Diagnosis : Pathways in Neurological Diagnosis Hypotheticodeductive Method Pattern recognition Hypotheticodeductive system : Hypotheticodeductive system Observations early on Hypothesis (Broad and Vague) Conclusions Revision of conclusion Alternate hypothesis Rapid and multiple hypothesis Pattern Recognition : 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 : Thank You

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