Download - Approach to Neurological Disease
![Page 1: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/1.jpg)
ThinkinglikeneurologistIsitdifference?
Dr.SuratTanprawate,MD,FRCP(T)NorthernNeuroscienceCenter
ChiangmaiUniversity
![Page 2: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/2.jpg)
ThinkinglikeaNeurologist
Where‘sthelesion?
What’sthelesion?
Simplyword
Complexway
![Page 3: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/3.jpg)
Seriesofstepstocollectdata
Chiefcomplaint
History
Confirma<onofanatomicallocaliza<on
Possibleanatomicallocaliza<onande<ologies
Task Goal
ReviewofPa<ent‐specificfeature
Listofpossibledisease
Neurologicalexamina<on
Possibleanatomicallocaliza<onande<ologies
RankoforderofLikelihoodofpossibledisease
Differen<aldiagnosis
![Page 4: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/4.jpg)
Complexbrainprocessing
![Page 5: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/5.jpg)
HowtobeJedi…
• Symptomsapproach
• Basicneuroanatomy
• Basicneurophysiology
![Page 6: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/6.jpg)
Symptomsapproach‐1
• Disorderofconsciousness– Levelofconsciousness– Contentofconsciousness
• Mentaldisorder– Memory– Intelligence– Personality– Behavioral– Demen<a
• Highercor<calfunc<ondisorder– Apraxia,aphasia,agnosia,
others
• Visualdisorder– Visualloss– Diplopia
Inyourhead
![Page 7: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/7.jpg)
Symptomsapproach‐2
• Languageandspeechdisorder– Dysarthria– Dysphasia
• Lowercranialnervedisorder– Deafness/<nnitus– Ver<go– Balance/staggering– Swallowing– Voicechange
Inyourhead
![Page 8: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/8.jpg)
Symptomsapproach‐3
• Sensorydisorder– Paindisorder
• Headacheandfacialpain
• Otherspaindisorder
– Numbness/<ngling
• Motordisorder– Weakness
– Movementdisorder
• Sphincterdisorder
Inyourhead
![Page 9: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/9.jpg)
Symptomsapproach‐4
• Episodicdisorder– Seizure/epilepsy– Syncope– TIA– Abnormalmovement
–Migraine
Inyourhead
![Page 10: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/10.jpg)
Skilltocollectthedata
Chiefcomplaint–Gettherightdata– Firststeptoapproach
ConsistofGroupsymptoms+Modeofonset
![Page 11: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/11.jpg)
Commonmisinterpretsymptoms
• PalalysisVSnumbness
• DizzinessVSweaknessVSFa<gueVSataxia
• DysphasiaVSdysarthria
• BlurvisionVSDiplopia
• Blackout:lossofconsciousnessVSlossofvisionVSsimpleconfusion
![Page 12: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/12.jpg)
Presentillness
SymptomsClarifysymptom
Onset,dura<on,progression
Onset
Somedisability
![Page 13: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/13.jpg)
DatafromCCandPI:
What’sandwhere‘sthelesion?
Ifcannotinterpretedthedata
Recollectthedata
![Page 14: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/14.jpg)
Neurologicalexamina<on
• Focusedneurologicalexamina<on– Detailofneurologicalfunc<onthatrelevanttothehistory
– Specificneurologicalexamina<on
• Screeningneurologicalexamina<on– Checkremainingpath.
• Recordneurologicalsign– PresenceVSAbsence
– HardsignsVSSo_signs
– NormalVSabnormal
– Lateralizingsign:• TrueVSfalselocalizingsign
• Normalvaria<on
![Page 15: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/15.jpg)
Generalneurologicalexamina<on
• Mentalstatus• Cranialnerve
– 1‐12CNfunc<on
• Limb– Voluntarymovement
– Muscle:bulk,tone,power– Coordina<on:FTN,HTS,rapid
alterna<ngmovement
– Reflex:tendon,plantarresponse
– Sensa<on:pinprick,JPS,vibra<onsense
• Gaitandbalance• Rombergtest
![Page 16: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/16.jpg)
Conceptof“so_”neurologicalsign
• “Hardsign”:– neurologicalsignresultfromalesionataknownsiteorthataffectaknownpathway
• “So_sign”:– anystructuralorfunc<onaldevia<onfoundmorefrequentlyinbrainimpairmentpersonsthaninnormalpersons
– Butdoesnotcorrelatewithanypar<culartypeofbrainlesionatanypar<cularsite,orinterrup<onofanypar<culartract
![Page 17: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/17.jpg)
Conceptof“false”localizingsign
• TruesignthatoccurssecondarytoalesionelsewhereintheCNS.
• Thesignisnotfalse,butisdistantfromtheactualsiteofprimarylesion
• Cause:– Shi_ofbrain:compressordisplacestructure(distant)orbloodvessel(ACA,MCA)
– Hydrocephalus:CN6palsy,Pretectal(sylvian)syndrome
![Page 18: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/18.jpg)
Differen<aldiagnosis
Discussioneachproblemlist
• 1)
• 2)
• 3)
• 4)
• 5)
![Page 19: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/19.jpg)
ListofproblemsIntegrateofHistoryandPE
• First:anatomicallocaliza<onoflesionorneurologysystem– Focal,Mul<‐focal,Diffuse
– Nuclear,tract,systemdisorder
– CNS,PNS,Boths
• Second:causeoflesion– Congenital,Gene<c
– Trauma
– Tumor
– Infect/Inflamma<on
– Vascular– Toxic/metabolic/Nutri<onal
– Degenera<on/Demyelina<on
– Idiopathic
– Psychogenic
![Page 20: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/20.jpg)
Thinkingoutsidethebox
![Page 21: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/21.jpg)
Example
• Female,35Y.O:SLEpa<ents,onpred.5mg/d
• PresentedwithacuteRt.Hemiparesis1dPTA
• CTbrain:acuteLt.MCAinfarc<on
• Atadmission:EKG:AFwithRVR,CHF
• Summaryofproblemlist– Acutestroke– AFwithCHF– SLEonpred.
![Page 22: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/22.jpg)
Organizedyourthought
AFwithCHF
SLEAcutestroke
![Page 23: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/23.jpg)
AcutestrokefromAFOthersproblemisSLE
Acutestrokefromothercaused(non‐AF)SLEassociatedcausedofstroke(vasculiPs,APL)SLEtreatmentassociatedcausedofstroke(infecPon)AFcancausedbystoke?
AcutestrokefromAFAFfromcardiPsCardiPsfromSLE
![Page 24: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/24.jpg)
SLEcancausedacutestroke:direct:vasculiPs,APLAb
Indirect:cardiPs,autoimmuneendocardiPs
AF:direct:cardiPs
indirect:Associatedautoimmunethyrotoxicosis
ExerciseyourthoughtprocessbyDiscussionbedsideCaserecord(MGH)
![Page 25: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/25.jpg)
EquipmentNeeded
• ReflexHammer• 128and512(or1024)Hz
TuningForks
• ASnellen’sEyeChartorPocketVisionCard
• PenLightorOtoscope
• WoodenHandledColonSwabs
• PaperClips
![Page 26: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/26.jpg)
![Page 27: Approach to Neurological Disease](https://reader035.vdocuments.net/reader035/viewer/2022062318/552928fb4a79596d158b4682/html5/thumbnails/27.jpg)
“Neurologytutorialprogramformedicalresident”
Neurologicalsymptomatology
Emergencyneurology
Diseasebasedorientedapproach