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

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

3. 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

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

5. 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

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

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

17. THANK YOU