APPROACH TO NEUROLOGIC DIAGNOSIS ERMAN C. FANDIALAN MD FPNA UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER

STEPS TO FOLLOW IN A PATIENT PRESENTING WITH NEUROLOGIC SIGNS AND SYMPTOMS A. DATA GATHERING B. ANATOMIC LOCALIZATION C. ETIOLOGIC DIAGNOSIS

Interpret data in terms of neuroanatomy and physiology Elicit clinical facts By history And by neurologic exam Interpret data in terms of neuroanatomy and physiology

Syndromic formulation Anatomic localization Syndromic diagnosis+mode of onset+lab test PATHOLOGIC OR ETIOLOGIC DIAGNOSIS

HISTORY TAKING 1. Special care must be taken to avoid suggesting to the patient the symptoms that one seeks e.g. asking the patient to choose a single word to describe his dizziness 2. Pls do symptom analysis- mode of onset,evolution, character,aggravating ang relieving factors, setting in which the illness occurred, location e.g. headache- throbbing- migraine Band like- tension headache

HISTORY TAKING 3. As neurologic diseases often impair mental function, it is important for the physician to decide whether patient is competent to give the history 4. If patients memory, attention and coherence is inadequate, ask the relative, friend or the employer who witnessed the attack.

THE NEUROLOGIC EXAMINATION 1. TESTING OF HIGHER CORTICAL FUNCTION 2. TESTING OF CRANIAL NERVES 3.TESTING OF MOTOR FUNCTION 4. TESTING OF SENSORY FUNCTION 5. TESTING OF REFLEXES 6. TESTING OF GAIT AND COORDINATION

ANATOMIC LOCALIZATION BENEFITS OF LOCALIZATION 1. It directs the diagnosis or work up E.g. if the localization points to a muscle disease, then you will order emg-ncv or cpk mm 2. It estimates the extent of the lesion e.g. a subcortical stroke or lacunar infarct as against an mca infarction It limits differential diagnosis

HOW DO WE LOCALIZE ? 1. List down all abnormal signs- it is derived from a good and adequate neurologic examination 2. Determine all anatomic correlates- example, a patient with right sided weakness may involve, the left motor cortex, the corticospinal tract etc. 3. LOOK FOR THE INTERSECTION This is your localization

ANATOMIC LOCALIZATION UPPER MOTOR NEURON LOWER MOTOR NEURON Muscles affected in groups Atrophy is slight and of disuse Spasticity Hyperactive reflexes Presence of Babinski Absent Fasciculation Individual muscles maybe affected Atrophy pronounced Flaccidity Normal or hyporeflexia Absent Babinski Fasciculations present

UPPER MOTOR NEURON A.Supratentorial 1. Cortical- abnormal MSE + long tract signs 2. Subcortical- internal capsule, thalamus, basal ganglia B. Infratentorial 1. Brainstem- crossed paralysis, ipsilateral cranial nerve involvement and contralateral long tracts 2. Cerebellum- vertigo and imbalance 3. Spinal cord- usually follows dermatomal or myotomal involvement

LOWER MOTOR NEURON 1. Anterior Horn Cell- combination of upper motor neuron and lower motor neuron manifestation 2. Roots- generally there is pain 3. Peripheral Nerves- stocking and glove distribution, distal and symmetrical 4. Neuromuscular junction- fluctuating weakness 5. Muscle- proximal and symmetrical weakness

Ant. Horn cell roots Peripheral nerves Neuromuscular junction muscles motor +++ sensory (-) others UMN+LMN polio Pain sciatica Distal symmetrical dm neuropathy Fluctuating weakness Myasthenia Proximal and symmetrical, atrophy pronounced Myositis

ETIOLOGIC DIAGNOSIS TEMPORAL PROFILE FOCAL OR DIFFUSE PERTINENT CVD DEMYELINATING INFECTIONS METABOLIC TRAUMATIC NEOPLASTIC DEGENERATIVE TEMPORAL PROFILE ACUTE ACUTE, OR CHRONIC ACUTE OR CHRONIC CHRONIC FOCAL OR DIFFUSE FOCAL DIFFUSE OR FOCAL DIFFUSE FOCAL MAYBE DIFFUSE PERTINENT RISK FACTORS PRECEEDED BY INFECTIONS FEVER PUPILS SPARED TRAUMA HEADACHE PROGRESSIVE

Clinical pearls 1. Focus the clinical analysis on the principal symptom and signs and avoid being distracted by minor symptoms and uncertain clinical data. 2. Avoid early closure of diagnosis. 3. When several of the main features of a disease in its typical form are lacking, an alternative diagnosis should be made. 4. It is preferable to base diagnosis on the clinical experience with the dominant symptoms and signs and not on statistical analysis of the frequency of the clinical phenomena.

DIAGNOSTIC MODALITIES 1. EEG 2. Cranial CT Scan 3. MRI 4. Lumbar puncture 5. EMG-NCV 6. Others

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