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    Approach To Neurological Disease

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    NEuRoLoGisT CoFFeeCuP
    This document discusses how neurologists think through cases by localizing lesions and determining etiologies. It outlines a step-by-step process including collecting the chief complaint, history of present illness, performing a neurological exam, generating a differential diagnosis, and thinking broadly about potential causes. Key aspects of the neurological exam like distinguishing hard from soft signs and false localizing signs are also explained. The document emphasizes practicing these evaluation skills to think like a neurologist.

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    Approach To Neurological Disease

    Uploaded by

    NEuRoLoGisT CoFFeeCuP
    1K views27 pages
    This document discusses how neurologists think through cases by localizing lesions and determining etiologies. It outlines a step-by-step process including collecting the chief complaint, history of present illness, performing a neurological exam, generating a differential diagnosis, and thinking broadly about potential causes. Key aspects of the neurological exam like distinguishing hard from soft signs and false localizing signs are also explained. The document emphasizes practicing these evaluation skills to think like a neurologist.

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    This is my view about approaching to neurological diagnosis.

    Original Title

    Approach to Neurological Disease

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    This document discusses how neurologists think through cases by localizing lesions and determining etiologies. It outlines a step-by-step process including collecting the chief complaint, history of present illness, performing a neurological exam, generating a differential diagnosis, and thinking broadly about potential causes. Key aspects of the neurological exam like distinguishing hard from soft signs and false localizing signs are also explained. The document emphasizes practicing these evaluation skills to think like a neurologist.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF or read online from Scribd
    Download as pdf
    1K views27 pages

    Approach To Neurological Disease

    Uploaded by

    NEuRoLoGisT CoFFeeCuP
    This document discusses how neurologists think through cases by localizing lesions and determining etiologies. It outlines a step-by-step process including collecting the chief complaint, history of present illness, performing a neurological exam, generating a differential diagnosis, and thinking broadly about potential causes. Key aspects of the neurological exam like distinguishing hard from soft signs and false localizing signs are also explained. The document emphasizes practicing these evaluation skills to think like a neurologist.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF or read online from Scribd
    Download as pdf
    of 27

    Thinking
like
neurologist

    Is
it
difference?

    Dr.
Surat
Tanprawate,
MD,
FRCP(T)
    Northern
Neuroscience
Center
    Chiangmai
University
    Thinking
like
a
Neurologist

    Where
‘s
the
lesion?
    What’s
the
lesion?

    Simply
word
    Complex
way
    Series
of
steps
to
collect
data
    Task
 Goal

    Chief
complaint
    Possible
anatomical
localiza<on

    and
e<ologies
    History

    Possible
anatomical
localiza<on

    and
e<ologies
    Neurological
    examina<on Confirma<on
    of
anatomical
localiza<on
    List
of

    possible
disease Review
of
    Pa<ent‐specific
feature
    Rank
of
order
of
    Differen<al
diagnosis
    Likelihood
of
possible
disease
    Complex
brain
processing
    How
to
be
Jedi…

    • Basic
neuroanatomy
    • Basic
neurophysiology

    • Symptoms
approach
    Symptoms
approach‐1

    • Disorder
of
consciousness
    In
your
head – Level
of
consciousness
    – Content
of
consciousness
    • Mental
disorder
    – Memory
    – Intelligence
    – Personality
    – Behavioral

    – Demen<a

    • Higher
cor<cal
func<on

    disorder
    – Apraxia,
aphasia,
agnosia,

    others
    • Visual
disorder
    – Visual
loss
    – Diplopia
    Symptoms
approach‐2
    • Language
and
speech
 In
your
head
    disorder
    – Dysarthria
    – Dysphasia

    • Lower
cranial
nerve

    disorder
    – Deafness/<nnitus
    – Ver<go
    – Balance/staggering
    – Swallowing
    – Voice
change
    Symptoms
approach‐3


    In
your
head • Sensory
disorder
    – Pain
disorder
    • Headache
and
facial
pain
    • Others
pain
disorder
    – Numbness/<ngling
    • Motor
disorder

    – Weakness
    – Movement
disorder
    • Sphincter
disorder
    Symptoms
approach‐4
    • Episodic
disorder In
your
head
    – Seizure/epilepsy
    – Syncope
    – TIA
    – Abnormal
movement
    – Migraine

    Skill
to
collect
the
data

    
 Chief
complaint
    – Get
the
right
data
    – First
step
to

    approach

    Consist
of

    Group
symptoms+

    Mode
of
onset
    Common
misinterpret
symptoms

    • Palalysis
VS
 • Blur
vision
VS

    numbness Diplopia
    • Dizziness
VS
 • Blackout:
loss
of

    weakness
VS
Fa<gue
 consciousness
VS
loss

    VS
ataxia of
vision
VS
simple

    • Dysphasia
VS
 confusion
    dysarthria
    Present
illness

    







Symptoms
    Clarify
symptom
    Onset,
dura<on,
progression

    Some
disability

    Onset
    Data
from
CC
and
PI:

    What’s
and
where
‘s
the
lesion?


    If

can
not
interpreted
the
data
    Recollect
the
data
    Neurological
examina<on
    • Focused
neurological
 • Record
neurological
sign

    examina<on
 – Presence
VS
Absence
    – Detail
of
neurological
 – Hard
signs
VS
So_
signs
    func<on
that
relevant
to
 – Normal
VS
abnormal
    the
history
    – Lateralizing
sign:

    – Specific
neurological
 • True
VS
false
localizing
sign
    examina<on • Normal
varia<on
    • Screening
neurological

    examina<on
    – Check
remaining
path.
    General
neurological
examina<on
    • Mental
status • Gait
and
balance
    • Cranial
nerve
 • Romberg
test
    – 1‐12
CN
func<on
    • Limb

    – Voluntary
movement
    – Muscle:
bulk,
tone,
power

    – Coordina<on:
FTN,
HTS,
rapid

    alterna<ng
movement
    – Reflex:
tendon,
plantar

    response
    – Sensa<on:
pinprick,
JPS,

    vibra<on
sense
    Concept
of
“so_”
neurological
sign
    • “Hard
sign”:

    – neurological
sign
result
from
a
lesion
at
a
known

    site
or
that
affect
a
known
pathway
    • “So_
sign”:

    – any
structural
or
func<onal
devia<on
found
more

    frequently
in
brain
impairment
persons
than
in

    normal
persons
    – But
does
not
correlate
with
any
par<cular
type
of

    brain
lesion
at
any
par<cular
site,
or
interrup<on
of

    any
par<cular
tract
    Concept
of
“false”
localizing
sign
    • True
sign
that
occurs
secondary
to
a
lesion

    elsewhere
in
the
CNS.

    • The
sign
is
not
false,
but
is
distant
from
the

    actual
site
of
primary
lesion
    • Cause:
    – Shi_
of
brain:
compress
or
displace
structure

    (distant)
or
blood
vessel
(ACA,
MCA)
    – Hydrocephalus:
CN
6
palsy,
Pretectal
(sylvian)

    syndrome
    Differen<al
diagnosis
    Discussion
each
problem
list
    • 1)
    • 2)
    • 3)
    • 4)
    • 5)
    List
of
problems
    Integrate
of
History
and
PE
    • First:
anatomical
localiza<on
 • Second:
cause
of
lesion
    of
lesion
or
neurology
 – Congenital,
Gene<c
    system – Trauma
    – Focal,
Mul<‐focal,
Diffuse – Tumor
    – Nuclear,
tract,
system
disorder – Infect/Inflamma<on
    – CNS,
PNS,
Boths – Vascular
    – Toxic/metabolic/Nutri<onal
    – Degenera<on/Demyelina<on
    – Idiopathic
    – Psychogenic

    Thinking
outside
the
box
    Example

    • Female,
35
Y.O:
SLE
pa<ents,
on
pred.
5
mg/d
    • Presented
with
acute
Rt.
Hemiparesis
1
d
PTA
    • CT
brain:
acute
Lt.
MCA
infarc<on
    • At
admission:
EKG:
AF
with
RVR,
CHF
    • Summary
of
problem
list
    – Acute
stroke
    – AF
with
CHF
    – SLE
on
pred.
    Organized
your
thought

    AF
with

    CHF

    Acute

    SLE
    stroke
    Acute
stroke
from
AF
    Others
problem
is
SLE

    Acute
stroke
from
AF
    AF
from
cardiPs
    CardiPs
from
SLE

    Acute
stroke
from
other
caused(non‐AF)
    SLE
associated
caused
of
stroke(vasculiPs,
APL)
    SLE
treatment
associated
caused
of

    stroke(infecPon)
    AF
can
caused
by
stoke?
    SLE
can
caused

    acute
stroke:
direct:
vasculiPs,
APL
Ab
    Indirect:
cardiPs,
autoimmune

    endocardiPs
    AF
:
direct:
cardiPs
    indirect:
Associated
autoimmune

    thyrotoxicosis

    Exercise
your
thought
process
by

    Discussion
bedside
    Case
record(MGH)
    Equipment
Needed

    • Reflex
Hammer

    • 128
and
512
(or
1024)
Hz

    Tuning
Forks

    • A
Snellen’s
Eye
Chart
or

    Pocket
Vision
Card

    • Pen
Light
or
Otoscope

    • Wooden
Handled
Colon

    Swabs

    • Paper
Clips

    “Neurology
tutorial
program
for

    medical
resident”

    Neurological
symptomatology
    Emergency
neurology
    Disease
based
oriented
approach

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