1. Approach to the Patient with Neurologic Disease Neuroscience Module Year Level 7 SY 2010-2011

2. Neurologic Method Step 1 : Locate the Lesion “where is the lesion?” Step 2 : Define the pathophysiology “what is the lesion?”

3. Neurologic Method CNS Cerebral cortex Basal ganglia Brainstem, Cerebellum Spinal cord PNS Nerve roots Plexus Motor nerves Sensory nerves MeningesNeuromuscular junction Muscle Upper Motor NeuronLower Motor Neuron

4. Neurologic Method Focal? Mulitifocal? Diffuse? Secondary to a Systemic illness? History - provides clues in localization Neurologic Examination - confirms and rules out

5. Neurologic Method Disturbances of Cerebrospinal Fluid and Its Circulation, including Hydrocephalus, Pseudotumor cerebri, and Low-Pressure Syndromes Intracranial Neoplasms and Paraneoplastic Disorders Infections of the Nervous System and Sarcoid Viral Infections of the Nervous System and Prion Diseases Cerebrovascular Diseases Craniocerebral Trauma Multiple Sclerosis and Allied Demyelinative Diseases The Inherited Metabolic Diseases of the Nervous System Developmental Diseases of the Nervous System Degenerative Diseases of the Nervous System The Acquired Metabolic Diseases of the Nervous System Diseases of the Nervous System due to Nutritional Deficiency Alcohol and Alcoholism Disorders of the Nervous System due to Drugs and Other Chemical Agents Major Categories of Neurologic Disease

6. Steps in the Diagnosis of Neurologic Disease Elicitation of Clinical Facts By history By neurologic examination Interpretation of symptoms and signs in terms of physiology and anatomy Syndromic formulation and localization of lesion ANATOMIC DIAGNOSIS Anatomic diagnosis+Mode of onset and course+ Other medical data+Appropriate lab tests Pathologic or etiologic diagnosis

7. Neurologic History Often permits an accurate localization and determination of probable cause of the complaints, even before the neurologic examination is performed Brings to focus the neurologic examination that follows Each complaint should be pursued as far as possible- "What are the associated features?"

8. Neurologic History Temporal course of the illness  Time of appearance  Rate of progression of the symptoms  Rapid, gradual, transient, stuttering, relapsing remitting Patients' descriptions of the complaint  The same words often mean different things to different patients

9. Neurologic History Corroboration of the history by others  Factors may impair patient's capacity to communicate  Episodes of loss of consciousness Family History  Many neurologic diseases have an underlying genetic component

10. Neurologic History Medical illnesses  Neurologic diseases occur in the context of systemic disorders (DM, hypertension) Drug use and abuse and toxin exposure  Prescribed and illicit Formulating an impression of the patient

11. Taking the History Avoid leading questions, encourage to give accurate description of the symptom Take notes, verify the history The setting, mode of onset and evolution and course are important Decide if the patient is competent to give a history

12. The Purpose of the Clinical Method of Neurology Accurate Diagnosis Determine the proper treatment Helpful in prognosis Genetic counseling Initial step in the scientific study of clinical phenomena and disease

13. Neurologic Examination Needs practice Essential for ALL clinicians for screening for neurologic dysfunction Performed in an orderly and systemic fashion to avoid errors and serious omissions

14. Neurologic Examination Describe what is found Compare the patients performance on tasks that require simultaneous activation of both cerebral hemispheres Reproduce the activity that elicits the symptoms Use of tests tailored to the patients problem can be of value in assessing changes

15. Neurologic Examination Begins with observation of the patient Ends as the last part of the general physical examination Performed and recorded in sequential manner Thoroughness governed by clinical problem Modified according to the condition of the patient

16. Neurologic Examination Testing of Higher Cortical Functions mini-mental examination Testing of Cranial Nerves Somatic Motor Somatic Sensory

17. Neurologic Examination

18. Mental Status Examination Level of conciousness  Awareness of self and environment  Describe the responses to the minimum stimulus necessary to elicit a reaction Orientation  Name, location and time Speech  Articulation, rate, rhythm, and prosody

19. Mental Status Examination Language  Content of patients verbal and written output  Response to verbal commands  Ability to read Memory  Immediate memory  Short term memory  Long term memory

20. Mental Status Examination Fund of Information  Inquire about major historic or current events Insight and Judgement  How patient would respond to situations with a variety of outcomes Abstract Thought  Describe similarities between various objects  List items of the same attributes

21. Mental Status Examination Calculation Ability  Have patient carry out a computation that is appropriate to the patient's age and education  Word problems involving simple arithmetic

22. Mental Status Examination Intergrative sensory function astereognosis agraphesthesia two-point discrimination allesthesia extinction unilateral neglect and anosognosia disorders of spatial thought Integrative motor function apraxia

23. Mini Mental Status Examination Orientation TIME year, season, date, day, month (1 point each) PLACE state, country, town, hospital, floor (1 point each ) Registration Repeat names of 3 objects (1 point per object)

24. Mini Mental Status Examination Attention and Calculation Serial 7’s or spell a 5 letter word backward (1 point per subtraction or letter) Recall Recall names of three objects repeated previously (1 point per object)

25. Mini Mental Status Examination Language Name a pencil, and watch (1 point each) Repeat “no ifs, ands or buts”(1 point) Follow a 3-stage command (1 point per step) Read and obey the command (1 point) Write a complete sentence (1 point)

26. Mini Mental Status Examination Construction copy two intersecting pentagons (1 point) TOTAL = 30 score of <24, more detailed investigation

27. Points Orientation Name: season/date/day/month/year5 (1 for each name) Name:hospital/floor/town/state/country5 (1 for each name) Registration Identify three objects by name and ask the patient to repeat3 (1 for each object) Attention and calculation Serial 7s; subtract from 1005 (1 for each subtraction) Recall Recall the three objects presented earlier3 (1 for each object) Language Name pencil and watch2 (1 for each object) Repeat "No ifs, ands or buts"1 Follow a 3-step command (e.g., "Taek this paper, fold it inhalf, and place it on the table" 3 (1 for each command) Write "close your eyes" and ask patient to obey writtent command 1 Ask the patient to write a sentence1 Ask the patient to copy a design (e.g. intersecting pentagons)1 Total30

28. Cranial Nerves CN I - smell CN II - acuity, peripheral fields, inattention, pupillary light reflexes and size of pupils, opthalmoscopy CN III, IV, VI - ocular movements, convergence, nystagmus CN V - inspect masseter, temporalis tone/bulk, corneal reflex, sensory V1, V2, V3

29. Cranial Nerves CN VIII - otoscopy, threshold and acuity, Rinne, Weber, vestibular function CN IX, X - phonation, nasality, swallowing, gag reflex CN XI - SCM, trapezius CN XII - lingual articulation, midline, lateral protusion, atrophy, fasciculations

30. Somatic Motor System Inspection Palpation Speed, strength of movement Muscle bulk, tone, coordination Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

31. Muscle Stretch Reflexes Jaw jerk Biceps (C5-6) Triceps (C7-8) Finger flexion (C7-T1) Quadriceps (L2-4) Ankle jerk (L5-S1-3) Cutaneous abdominal Plantar 2 2 2 2 22 22 11 + + ++

32. Cerebellar System Finger to nose, rebound, alternating movements Heel to knee Nerve root stretching tests Nuchal rigidity Leg raising tests

33. Somatic Sensory System Superficial sensory modalites Light touch Pain Temperature Deep sensory modalies Vibration Position Sense Stereognosis Romberg swaying test

34. Signs CerebrumAbnormal mental status or cognitive impairment Seizures Unilateral weakness a and sensory abnormalities including head and limbs Visual field abnormalities Movement abnormalities (e.g., diffuse incoordination, tremor, chorea) BrainstemIsolated cranial nerve abnormalities (single or multiple) "Crossed" weaknessa and sensory abnormalities of head and limbs, e.g., weakness of right face and left arm and leg Spinal cordBack pain or tenderness Weakness a and sensory abnormalities sparing the head Mixed upper and lower motor neuron findings Sensory level Sphincter dysfunction Table 361-2 Findings Helpful for Localization Within the Nervous System

35. Signs Spinal rootsRadiating limb pain Weakness b or sensory abnormalities following root distribution (see Figs. 25-2 and 25-3) Loss of reflexes Peripheral nerveMid or distal limb pain Weakness b or sensory abnormalities following nerve distribution (see Figs. 25-2 and 25-3) "Stocking or glove" distribution of sensory loss Loss of reflexes Neuromuscular junction Bilateral weakness including face (ptosis, diplopia, dysphagia) and proximal limbs Increasing weakness with exertion Sparing of sensation MuscleBilateral proximal or distal weakness Sparing of sensation Table 361-2 Findings Helpful for Localization Within the Nervous System